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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 PERMIT EXPIRES 1 YEAR FROM DATE S (Complete in Triplicate) I 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Be ices. I,ot Size/Acreage r _ - Job Address -City'- Ja' Owner's Name Addres --- Phone 93/— z Contractor Z AA ddress r262a License No.�& Phone TYPE OF WELL/PUMP: NE7 WELL WELL REPLACEMENT n DESTRUCTION 0 Out of service well ❑ PUMP INSTALLATION SYSTEM REPAIR O OTHER ❑ Monitoring N?11 ❑ DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. -"' PROP. LINE /� FOUNDATION ,fi2�// r_ AGRICULTURE WELL � OTHER WELL � PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u C7 Industrial ❑ Open.Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing XDomestic/Private 1100ravel Pack L7 Tracy Type of Casing_ - -Specifications V1 Public n; 1 Other fl Delta Depth of Grout Seal Type of Grout t I 1 1 Irrigation protc.yDepth I I Eastern Surra a Seal Installed by ` Repair Work Done U Type of`Pump _,-45 H.P. Z State Work Done t Well Destruction ❑ Well Diameter Sealing material tr Depth ' Depth Filler Material i Depth ; TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION f I (No septic system permitted it public sewer is aviilible within 204 feet.) ON _Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms ;e Character of twit to a depth of 3 feet: !'' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity a � No. Compartments j PKG.'TREATMENT PLT.0 E j Method of Disposal Distance to nearest: Well Foundation Property-Line LEACHING UNE El No. b Length of lines :Total length/size FILTER BED ❑ Distance to.nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Numbers SUMPS Ll Distance to_near*sf:, _' Well 't Foundation--- Property Line '- DISPOSAL PONDS I hereby certify that I have prepared thin application and.•thpt the work-will be done in accdrdance,with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County.,--- Home ounty./Home owner or licensed nt's nature certifies the followin "I certify that in the rformance of the work for which this permit is issued, I shall•noi r aBe sig 9: pe �-.\;;--, employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature , tartifies the following:,'I certify that in the performance of tlia'woik for which this permit is isiued',Y•shall employ persons subject to workman's compensa• ` tion laws of California." 1 `� The"icon1 uir Complete drawing on reverse Signed Date: TM .. i •dit,, - a — t 1i F R DEPARTMENT USE O LY Appikstlon Accepted by .f 4 �� to �3 Date �7 Area Q7 'Z' Pit of ro Inspection by _ ato '- Final Inspection by-_-C_,4 _ /d Additional Comments:f Applicant - Return ali copies to: San Joaquin County Public Health Services A , e 4 Eavironmental 'Nealth'Per.mit/Services 1445 N San Joaquin; P O Box'2009, Stkn, CA 95201 CK tFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. INIF EN 11.2e EK 13-24111%E .1/nbl"