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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 PEMIT EXPIRES 1 YEAR FROM DATE (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 vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Bern ces. Job Address TZ Cityj�&& Lot Size/Acreage V Owner's-Name- W - Address_-_ - - — 3 - Phone Contractor "Address tl License NoL Phone / TYPE OF WELL/PUMA: NEW WELL ❑ • WELL''REPLACEMENT ❑ DESTRUCTION L1 Out of Service Well ❑ PUMP INSTALLATION O SYSTEM EPAIR 10 OTHER 0- Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Dl5P L FLD. JPROPyLfNE FOUNDATION AGRICULTURE WELL =HER WELL PITS/SUMPS INTENDED USE t TYPE OF WELL PROBLEM AREA CONSTR ION SPECIFICATIONS �I 0 Industria! '# ❑ Open Bottom ❑ Manteca Di W II Excavation Dia. of Well Casing n Oomestic/Private '❑'Grave! Pack 0 Tracy ype of axing_ Specifications !'1 Public Cl Other' I-1 Delta Depth o Grout Seal ...._,Type of Grout I I Irrigation _.Approx. Depth I I East Surface Saal installed by Repair Work Done ❑ Typo of Pump H.P. State Work Dona Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material Z Depth 4 --- --r TYPE OF SEPTIC WORK: NEW INSTALLATION I&r REPAIR/ADDITION i^I .DESTRUCTION 1 I (No septic system P per if public sewer is i ,avails Is wit in 200 feet.) Installation will serve: Residence Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 Peat: l � �. I` a� star to depth SEPTIC TANK. ❑ Type/Mf � g Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: Wello nd tion ! Property r ! LEACHING LINE Cl No. b Length of Imes T of length/size- FILTER ength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line-_11 sem SEEPAGE PITS 11 Depth ..Number SUMPS C7 Distance to nearest: �IrNell' Foundations Vino --- Property Lino � " DISPOSAL PONDS, ❑ -� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county aidinances, state laws, and F rules and regulations of the San Joaquin County l 4 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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the of following: how Califoy 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 The applicant st all for dl ked`Ifis tions. Complete drawing on reverse sde. / Signed Title: ! � d Q3 Date: ti e F10 ,_,DEPARTMENT USE ONLY w k Application Accepted by _ � 1 Data 3 - {3 2 Area 11 Pit or Grout fns I peCtbn by Data Final Inspection by fDats 3 q (� Additional Comments.- Applicant omments;Applicant - Return all copies to: San Joaquin County Public- Health Services Environmental Health Permit/Services 445 N San Joaquin, O Box 2008, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED GK ' - 4.,INFO H RECEIVED BY DATE PERMIT'NO. t E 13-24(REV.1/"5) tEH 14-28S "'I k 14 r0-0, fi /