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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 IL XW 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. / t -� Job Address ,,._, 1 � Cit Got Size/Acreej , , -,- ?.- f' -4-7 Owner's Name Address 's 3ld Phone Contractor' d Address(&&E 76 Z License No. f_7-Z;4:Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 7F PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial 0 Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing 11 Domestic/Private 0 Gravel Pack7 ❑ Tracy Type of Casing_ Specifications Il Public ' [I Other it Delta Depth of Grout Seal Type of Grout (� I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by u) Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth t Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATIONX, R AI ADDITION I 1 DESTRUCTION i I (No septic system permilled it public sewer is available within 200 feet.) Installation will serve: Resi_dence /v Commercial_Other Number of living units: ._ Number of bedrooms Character of soA to a depth3 feet: Water table depth 0 SEPTIC TANK. IJ Type/Mfg ` Capacity Qo na No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal 1,, Distance to nearest:' Well �P Foundation s Property Line LEACHING LINE Ck' No. & Length of lines',_= d _ Total length/size 6 1 ,14,12= J FILTER BED 0 Distance to nearest: Foundation 10 Property Line SEEPAGE PITS d Depth _ v( .5 k:�t SizeNumber SUMPS _Ll ' Distance to nearest: Well b0Zr Foundation _ Property Line DISPOSAL-PONDS-—0 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 following: "i-certify that in the performance of the work for which this permit is issued, shall no _ employ any person in such manner ss to become subject to workman's compensation laws of California"�Contrsctor'a 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 t cell for all required inspections. Complete drawing on reverse side. Signed X Title: 44L121 Date: FOR DEPAR MENT USE ONLY � Z Application Accepted by '9 Jt _ Date Area Grout Inspection byDate�__.1��3 Final inspection by te� vAdditional Comments: I Applicant - Return all copies to: San Joaquin County Public Health Services 4 Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE I INFO AMOUNT DUE AMOUiNT[REMITTED CASH RECEIVED BY /^DATE PERMIT'NO. . EN rs2s rntzv.rRsr /f�rC1C� !(�� J�� Q t� 1 EN:4-M