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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 0 BOX 2009, STOCKTON, CA 95201 PERM T ESPIRES I 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 is made in compliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address P-0 City Lot Size/Acreage 030 M. -r--r- Z.-gA67 Owner's Name IA(,j MIReDf, 2 Address T12!C W=12 eV-.4 0 9.�7.4.5 Phone Contractoro �c u Q '" ! Address License No.��—V-Y/-3 Phone TYPE OF WELL/PUMP: NEW WELL I] WELL REPLACEMENT n DESTRUCTION ❑ Out or Service well ❑ PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well (3 (� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ,•jl�� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom . ❑ Manteca, Dia. of Well Excavation Dia. of Well Casing GY64mestic/Private ❑ Gravel Pack t C7 Tracy ' r, Type of Casing_ Specifications I'I Public 1-1 Other r 1'1 Delta _ - Depth of Grout Seal Type of Grout .. I I Irrigation —Approx. Depth- I I Eastern Surfac eal Installed by I Repair Work Done ❑ Type of Pump V�a H,.P.^ / State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth L{/t 7"L>� Depth >riller Material i Depth N UA T TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fest: �� ` " '""} l Water table depth SEPTIC TANK. ❑ Tye./Mfg Capacity --No... PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line �l LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line -DISPOSAL PONDS ❑ 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 follwing: "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: "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." The applicant all for all required ionspections.,Aomplele drawing on r r e si q Sleeted XTitle: . R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. INFO CASH . EM 1344 leEv.,,Kt, -0 old o EK 14.16IF rl�