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APPLICATION FOR PERMIT ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION r 445 N SAN JOAQUIN, PHONE (209)465-3420 i P O BOX 2009, STOCKTON, CA 95201 • 6 PERMIT EXPIRES 1 YEAR R M DATE SPEDQ ;i (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 ccupliance frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address il City _NA Lot Size/Acreage NA ISLAND Quad Owner's NameAw�dAddress . 148 Hniistan I�ka1-496-461 5 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER IA Ro``n ,toring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LIIVF" *ti FOUNOATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i I-] industrial. ❑ Open Bottom ❑ Manteca _ Die. of Well Excavation Dia. of Well Casing f-1 Domestic/Private ❑ Gravel Pack' 0 Tracy x Type of Casing_ Specifications ['I Public l"1 Other n Delta Depth of Grout Seal Type of Grout I' ! I Irrigation Approx. depth I I Eastern Surface Seal Installed by Repair Work pone ❑ Type of Pump f H.P. State Work Done_ Well Destruction ❑ Wall Diameter Sealing Material fr Depth Depth I Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is rn ,I . . available within 200 feet.1 Installation will nerve: Residence_ !'Commercial— Other Number of living units: Numbeitof bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to'nearest:, Well Foundation Property Line - l LEACHING LINE ❑ No. G Length of lines Total length/size FILTER BED ❑ Distance to;nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth {f Size Number SUMPS LI Distance to,riearest: Well Foundation Property Line DISPOSAL PONDS ❑ !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 Sen Joaquin County t 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 ampioy 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: "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." ` r The spplic ustIII for on red in lons. Complete drawing on reverse side. I I I Signed 4 Title: PERMIT AGENT Date: JR-1 —�? BOB LUCIDO rr x O EPARTMENT USE ONLY r �2 Application Accepted byDate Area Pit or Grout Inspection by x Date Final Inspection by Data Additional Comments: Applicant - Return all copied to: San Joaquin County Public Health Services /=pyWy Environmental-Health Permit/Services t 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTEDeCK RECEIVED BY GATE PERMIT'NO. . EM14.21(REV.r/Fitt77 EN f626 '•