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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 ROM DATE ItISUED (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 Catapliance with San Joaquin County Ordinance No. 549 and 18 and the Rules and Aegulationa of San Joaquin Count Public Health Servi `e I Job Address _,._��_ - - -- _ City Lot Size/Acreage Addres Phon.gA � v Re �}N,�am{e,, DC7 7' ---Con /U`"�'/�/ �d� No. honetar OF WELL/PUMP: NEW WEL WELL REPLACEMENT .. DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well n 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 \❑- Industrial O Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing `6�Qameslic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications it Public i l"1 Other f1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approxi Depth I I stern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P.LJ State Work Done_ Well Destruction ❑ Well Dismete Sealing Material i Depth rJ Tiller Material i Depth Depth f TYPE OF SEPTICWORK:_NEW INSTALLATION-I 1 REPAIR/ADOITION,i J DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial--ZOther F Number of living units: Number of bedrooms j �1�• Character of will to a depth of 3}set: t r Water table depth SEPTIC TANK ; 0 iTypa/Mfg Capacity No. Compartments PKG. TREATMENT.PLT. ❑ ; Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.b Length of lines 1 Total length/size l� FILTER BED ❑ Distance to nearest. Well t.-Foundation- Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS' ❑ 1 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 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 subcontracting 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 laws of Califorr4a." The applicant e, call far al ins tions'. Complete drawing on rev si 9. Sigma UTitle: Date: kX�g F011iiDEPARTMENT USE ONLY �-� f{ i Date ~�~0 L Area(1 1 Application Accepted f y D Pit of Grout Inspectn by rate Final Inspection by ats t7 17 Additional Common": � " a" ftx / Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ISI 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED BY DATE PERMIT'NO. INFO �^ CASH . EH U-21 t�tEV.IiFtsr {]a` � �j + O� Z ao/ EH 11-2a