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APPLICATION FOR PERidIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby mads to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public health Services. Job Address .� - JF ✓ City Lot Size/Acreage Owner's Name ,� / � Address Phone lel Contractor )A�7j:14i rest icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (A Domestic/Private Cl Gravel Pack7 ❑ Tracy Type of Casing Specifications 11 Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material A Depth n} Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i :REPAIR/ADDITION I I TRUCTIONI i iNo septic system permitted it public sewer is vailable within 200 feet.) Installation will serve Residence_.L_,-'Commercisl,_-_ Other l + f.� Number Of li�iinq units: Number o} ms—_ Character jof toll to aldepth of 3 feet:y Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.03 1 Method of Disposal 4 Distance to nearest: Well Foundation - Property Line L LEACHING LINE 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property.Line .�� SEEPAGE PITS I I Depth Size Number SUMPS Ll/6istancs to nearest: Well t A Foundation--ZL40 l _ Property Line �S DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin-County Home owner or licensed agent's signature certifies the following: "I Certit that.in the performance of the work}or which this permit is issued, I shall not employ any person in such manner as to become subject to workmsn's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Califar The applica t t cap rail in r s. Complete drawing on�side. /`Sig Title: ft J Date: x r FOR DEPARTMENT USE ONLY Application Accepted by Dats 1 �~ 2.._ Area 02- �Pft or Grout Irupiction by Data y Final Inspection by Data �J Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services _. 445 N San Joaquin, P O Box 2009, Stkn; CA-95201 4s INFOFEE AMOUNT DUE AMOUNT REMITTED CASH K 11 RECEIVED BY DATE PERMIT'NO. EM 3.24 / Y - qg EH ta