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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 PERMITEXPIRES 1 YEAR FROM DATE- ISSUED (Complete in Triplicate) Application is hereby made to BJoaquin County for a permit to construct and/or install the work herein described. This application is made in compliance liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health/Services. Job Address ' _ Cty i '" Lot Size/Acreage Owner's Name f �J } afV / U/YLL� Lddress ! y .3 � yti'/� = Phone Contractor_ __ _ Address License No. Phone TYPE OF WELL/PUMA: NEW WELL X WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION Q�' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK VA SEWER LINES y00- f- ----- DISPOSAL FLD. PROP. LINE FOUNDATION '11T0-)- __ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA 1CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing (� * Domestic/Private A Gravel Pack ❑ Tracy Type of Casing_,Q/%LJIY 4, /= Specifications \j I'1 Public 1a Other fl Delta Depth of Grout Seal Type of Grout "K Irrigation .2,!�'—OlApprox. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump .S"lJ 9 H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material li Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AOOIT10N I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) S. Installation will some: Residence— Commercial— Other Number of living units: Number of bedrooms Character of&Oil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No, S Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 regulation of the San Joaquin County Hann 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 not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature cartifi"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 C&lif(Wnls." The applicant gwst call for all ra ire inspections. Complete drawing on reverse side. y% `�/ � Signed X��f��,�1'T ; Title: !��- pace: FOR DEPARTMENT USE ONLY Application Accepted by XI �-� l�1ir7 Date S".2 le ZssZ Area u Pit of Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services t n M Environmental Health Permit/Services 445 N San Joaquin, P O BOA 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ryyPE�RtM1IT'N0. • EH ii IItEV. i n aY ?A) ate/