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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 -REPWIT EXPIRES 1 YEAR FROM DATE $SURD (Complete in Triplicate) A lication is`here C L {"f '� pp -hereby Ban Joaquin C(Amty for a perms to construct and/or install the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address f,4/ ULV/+ �Bf r C, �Ciity �'�I'��J A Lot Size/Acreage Owner's Name /� w/�t� Address �o,o00 05400',plr /7CP i_ Phone Contractor _U Address jmow w!� v�1 A/ License No. 7 K-5MY Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION C1 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well O DISTANCE TO NEAREST: SEPTdC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� Cl Industrial , ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing J3 e fa Domestic/Private ❑ Gravel Pack ' C1 Tracy Type of Casing_ Specifications i'I Public n Other n Delta Depth of Grout Seat Type of Grout - �3 I I Irrigation _Approx. Depth I I Eastern Sudscs Soul Installed by - Repair Work Done L] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth 1 Depth * Filler Material & Depth � TYPE OF.SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION Ar DESTRUCTION I I (No septic system permitted if public sewer.is . -� 1 I available within ZL10 teat.} ; Installation will serve: Residence_'L—Commercial - Other ;l- Number of living units: Number of bedrooms Character of sall to a depth of 3�feel: Water table depth �4 SEPTIC TANK D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl ` ... l Method of Disposal Distance to nearest: Well /Y/ Foundation Property Line 4 LEACHING LINE 0 No. 6 Length of lines Total length/size � FILTER RED 0 Distance to nearest: Well Foundation Property Line r. SEEPAGE PITS I I Depth f P —Size 6 Number � �,• SUMPS Al Distance to nearest: Well 1Y1,4 — Foundation i t7' _ Property Line_.1 DISPOSAL PONDS ❑ 5 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 Homo 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 net employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 compensre tion laws of Califonila." The applicant m t call for all required inspections, Complete drawing on reverse side. Signer Title: Date: 91-11(,V% OR D-WARTME SE ONLY Application Accepted by Date Ar ' s Pit or Grout Inspection by Data Final Inspection b Data � Additional Comments:. i Applicant - Return all -copies to: San Joaquia County Public Health Services Environmental Health Permit/Services ` ✓ 445 N San Joaquin, P 0 Box 2009, Stkn,'CA 95201 ill FEE AMOUNT DUF AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH . EH 13.24 IaEV.i i n 61 E_ EH 14.26 1. ZZ!Z s/