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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ;P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR PR s �. (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or,install the work herein described. This j application is mabe_.,,in coaj lance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulation of San Joaquin County Public-Health Services.. ,,,/� Job Address _ �5.�r ��n�� - CitY L0561 Lot 31ze/Acreage p I 11 Owner's Name."'`fRR�I�}� G' CXAddress Phone �� -� Y • Conlracfo 6"OSS RM S Address 6UIXLicense No. 30(o 22—. _Phone ya`18 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 Out of•Seryice W 11 0 + PUMP INSTALLATION (►dam SYSTEM REPAIR ❑ OTHER 0 Monitoring W.-11 C1 DISTANCE TO NEAREST:, SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `l FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS �. ._ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I :fin 11 Industrial pen Bottom 0 Manteca Die. of Well Excavation / Dia. of Well Casing ] U Domestic/Private ❑ Gravel Pack. 0 Tracy Type of Casing Specifications j M Public 9 f:1 Other © Delta Depth of Grout Seal -C7'__- _ Type of Grout I Irripauon.' , .aApproR, Depth fD East�rq[� Surface Seal installed by j Repair Work Done U Type of Pump. Sud° H.Pa I State Work Done� ► -� Well Destruction D Well Diameter ID Seali terial i Depth 1 Depth - - 1.1 TYPE OF SEPTIC WORK: NEW INSTA LATION❑ REPAIRIADDITION Cf .DESTAU TION G iNo septic system permitted if public soo ar is -available within 200 feet.) ` ..•YYY Installation will serve:. Residence Commercial_ Other Number ofrliving units: Numbe of bedrooms Character"of soil to a depth of 3 feet: Water table depth i SEPTIC TANK, D Type/Mfg Capacity No. Compartments. PKG. TREATMENT PLT. 0 ` Method of Disposal JI ' Distance to earest: I 1 Foundation Property Line ^4 LEACHING LINE ' _ + CI No. &.Lengtl of lines Total length/size FILTER BED Distance toarest: WeII �Ftoun tii� Property Line SEEPAGE PITS 11 De Size "f a" Q Number -SUMPS LI Distace t rest: Well oun alio rope Line DISPOSAL PONDS D .� f -`C. I hereby certify.that I have prepared this application and that the work will be done in acc((dancl with San Joaquin c u t inanc and n of the`San _ - 'Nome owner or ticenaad agent's signature certifies t .following: "I certify that in the performance of the work for which this permit is issued, I s all not employ any person in such manner as to become_subject to workman's compensation laws of California." Contractor's hiring or sub-contracting si ature �eertifies the following; "I certify that in the periorlh ar>Gd�of the work fa which this permit is issued, I shall employ persons subject to workman's com ansa- laws of Calilornla." �1l j The applicant mus call f uired inspections. Complete drawing on reverse side. Signed K Title: ._ DW11. A 2 Data: a i VOR DEPARTMENT USE ONLY meq_ Application Accepted by Date ►+ Z Area Pit or ou Inspection by Dat Final Final Inspection by �Z e � Additional Comments: Applicant ^ Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 88201FEE INFO AMOUNT DUE AMOUNT REMITTED f CASH RECEIVED BY DATE �/PERMIT'NO.Al cm log? + • EH 13-24(REV.rws) 1 7 � q • 2 — i EH C :v. 20 �D17 0 1Z`I —9L 2r — v. q _ 4