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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC IMALTH SERVICES ENVIRONUMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES M 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 MBAs in compliance with San Joaquin County Ordinance No 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services dL Job Address ✓ �� I �` City Lot Site/Acreage I �10 - - Owner s Name Tr�1�I�I 'i ��-- L Address 1F.�� LLY-E�,, �o��r. Phone Contractor Address r r' I License No £� ~� Phone ;'I TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT (1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATI N ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Yell DISTANCE TO NEAREST SEPTIC TANK M SEWER LINES DISPOSAL FLD PROP LINE FOUNDATION AGRICULTURE WELL !t OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Drs of Well Excavation i IL DIa of Well Casing )- 94 94 Domestic/Private O(Gravel Pack ❑ Tracy Type of Casing IVG Specifications 1 � I I Public fl Other ❑ Delta Depth of Grout Seal E Type of Grou I I Irrigation —Approx Depth I I Eastern Surface Seal installed by �� ItA79'� Of1fr�'r��Cr Repair Work Done U Type of Pump H P State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth r mat,3 4"oaitr? t kJ, Oepth Tiller Material A Depth TYPE OF SEPTIC WORK NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted If pirblIC rawer Is available within 200 feet 1 Installation wd)serve Residence— Commercial_ Other Number of living units -Number of bedrooms _ ~' Character of soil to a depth of 9 feet Water table depth SEPTIC TANK ❑ type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LIME Cl No 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 Norm 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 sub-contracting signature certifies the following '1 certify that to the performance of the work for which this permit Is issued,I shall employ persona subject to workman s compenss tion lava of California" The applicant II fo I r irad inspections Complete drawing on reverse side Signed �!Title ' _ f r' - Date // — FAR DEPARTMENT USE ONLY Application Accepted by Date �r� Z Ar a ' Pit or Grout Inspection by Date.�. -. Final Inspection by Date Oldditional Comments Applicant - Return all copies to San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2809, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C X'F RECEIVED BY DATE PERMIT NO �y SH L-? �EM 13.244REV t/x5 ifN t�2a v7