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M APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES a/ ENVIRONMENTAL HEALTH DIVISION 445 N SAN. JOAQUIN, PHONE (209)468-3420 �V P O BOX 2009, STOCKTON, CA 95201 PERMIT EUIRES 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 in made in compliance vith San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of Ban Joaquin County Public Sealth Services. Job Address O`T � �^"''�--' City Lot Size/Acreage Owner's Name Address Phone Contra C �e� Ad �7 License N Phone �*-� �'�a►e — f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service 'Well O PUMP INSTALLATION SYSTEM REPAIR CAS OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, - PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Wep Casing I-4-fr5eslic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public 1'1 Other fl Delta Depth of Grout Seal Type of Grout I I Iffl tion /`�Applox.'Depth I I Eastern Surface Seal Installed by Repair Work Done W Typs of Pump, f H.P. t� State Work Done Well Destruction ' ❑ Well Diameter Material A Depth Depth Filer Material A'Depth TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION'(.OP-DESTRUCTION I I (No septic system permitted it public sewer is available witMn 200 feet.1 �, \ Installation will serve: Residence_ Commercial Other .� Number of living units: Number of bedroom' . °.l Chiractar of soR to a depth of 3 feet: Water tabpAp SEPTIC TANK ❑ Type/Mfp - Capacity ' No. Come PKG, TREATMENT PLT.Cl —° —J „ Method o�pifp�al 9 1993 Distence'to nearest: Well Foundation Property Liney (� �lu+i,�naQuaN GOLI'' `rrv^, LEACHING LINE tl No. f1 Length of lines Total length/size Pt JPI-Ir, HEALTH SF v l FILTER BED O Ofstanci`to'nearaTt: alttwndation ropahvi Rip ENTA r - \ SEEPAGE PITS .-1-1 ,Depth -- Size Number SUMPS `.L� %=.Distance to nearest: Well Foundation ` `Piopeity Line DISPOSAL POWDS O' 1 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 certify that in the;performiance of the work for which this permit is issued, I shah not empty any person in such manner as to become subject to workman's comipensatiorl,'lsws of California."Contractor's hiring or sub-contracting signature certifies the foNowing: "I certify that in the perfomunce of the work for which this permlt is issued, I shah employ persons subject to workman's compensa- tion taws of California." The applicant r alt roquired ' spgctione. Complete drawing on arse side. t }� Signed X _ ,,�� Title: Date:�w�"" FOR DEPARTMENT USE ONLY Application Accepted by Date / Area Pit of Grout Inspection by Date Final Inspection by i 1M>7LU t� Date Additional Comments: r Applicant - Return all copies to: Stn Joaquin County Public Health Services Environmental Health Permit/Services 445 K Ban Joaquin, P x 2009, Stkn, CA 95201 FEE PUNT DUE AMOUNT REMITTED" s �A' ECEIV 0Y D TE PERMtT'NO. . EH t>ri{REV. 1/1151 �Z EN 141a