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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address a City Lot Size/Acreage AOwner's Name Address rr Contractor Address e,; License No.dWjZ L1 Phane TYPE OF WELL UMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION I SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well (3 DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD. -.PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing VI Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications Q l'I Public Ci Other 11 Delta Depth of Grout Seal Type of Grout I� I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 4 Type of Pump„� __ H.P.1„r %IQit. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I i 1No septic system permitted if public sewer is w available within M feet.! Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms r Character of soA to a depth of 3 feet: WaPAN%M SEPTIC TANK. ❑ Type/Mfg Capacity No PKG. TREATMENT PLT.❑ Me F W Distance to nearest: Well Foundation Property JU --a-Z- O.1J LEACHING LINE Cl No. 8 Length of lines Total lengtp!A FILTER BED 0 Distance to nearest: Well Foundation E!NWQ@ jL4EmTAI_HEALTH DIVSIGN SEEPAGE PITS I I Depth Size Number a rt w_ SUMPS LI Distance to nearest: Well � Foundation Prooertjr Line 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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature canifies 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 laws of California." The applicant must call for of quired inspections. Complete drawing on reverse side, Signed X >Yu"'"" `. Title: eea Z Date: 64�,r FOR DEPARTMENT USE ONLY Application Accepted by DateAip ra Pit or Grout Inspection by Date Final Inspection by Oat, Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED SY DATE PERMIT'NO. . 6H S-24 tltev.,,�sk .� - Sr /.236 tiH 1+•7e