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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION i� 445 N SAN JOAQUIN, PHONE (209)468-3420 li P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby madC to San Joaquin County for a permit to construct and/or Install the work herein described. This application is made in cc4lienee vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /j Job Address /�/ 7 r� ��"''gaTCity � �__ Lot Size/Acreage Owner's Namr�__ Address [A' � Phone ✓ V.2 Contractor_ C r� - Address License No.�Q` Phone��i`3� s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Kell ❑ .• PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring well C1 ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_ FLO. — PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �r *� CJ Domestic/Private a ❑ Gr: el Pack L1 Tracy Type of Casing Specificationa I'] Public j fl Other ❑ Delta Depth of Grout Seal Type of Grout i I Irritation' L.Approrr:Depth, I I Eastern Surface Seal Installed by Q Repair Work'Done U Type iof,Pump m H.P. State Work Done W ll Destruction ❑ Well Diameter , ,Sealirsg Material A Depth 1 Depth r ' Filler Material i Depth lav TYPE OF-SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( DESTRUCTION I I Mo septic system permitted if public sewer is t" available within 200 feet.) Installation,witl serve: Residence____ Commercial Other Number of living unite: _LJ Number o rooms 3 sgiL Character of soll to a depth ofi 3.fest: Water table depth �� r SEPTIC TANK._. ❑ Type/Mfg ` Capacity 24] 0 No. Compartments PKG. TREATMENT PL-T.,0: ` Method of Disposal / Dinar"to nearest: Well Foundation Property Line _t II r— LEACHING LINE IEEt—No. 6 Length'of lines _ �� Total length/size FILTER BED ❑ Distance to dearest: Well L671 Foundation _a7 f Property Line &240/ SEEPAGE,PI,TS 14—Depth Size Number ell SUMPSEli Distance to nearest: Well Foundation (0 0 ir Property_Line DISPOSAL PONDS ❑ I� t hereby certify that I have prepared this application and that the work will be done in accordance wifh San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Horne owner or licensed agent's signaturefcertifies the following: "I certify that in thepert rmance 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 f California." Contractor's hiring or sub-contracting signature cerdfiss the following: "I certify that in the performance of the work for which this ps►m. is i i uad, I shall employ persons subject to workman's compensa- tion laws of California.,., 0— The -rThe applica 11 forall 2�i tions. Complete drawing on reverse side. Signed KTitle: �GC�/�� Date: F R DEPARTMENT USE ONLY 1 Application Accepted by }}-- Date SIAL,�Q 1 _I_ Area Pk or Grout Inspection by ate Z_:� Final Inspection by to j Additional Comments: 17 hi. ,- Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health.Permit/Services 445 N San Joaquin, P 0 Boa 2009, Stkn, CA 95201 t IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT'NO. ' . EN 13.24 IREV.I I N 5) . � a b--9 3 q3 - 15 G i EN 14.29 i�