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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 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquia County Public Health Services. Job Address a7 7/0 a-en m-e/-f-- - City 't4' iZC�_ Lot Size/Acreage Owner's Name Address L' Phone LG Contractor r>`hg Address License No. LkT-A -Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 TC]�// ER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ^ SEWER LINES DISPOSAL FLD.102-_ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOkS f/ C7 Industrial ❑ pen Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casi [} Domestic/Private ravel Pack racy Type of Casing_ a Specifications I 1 Public 1-1 Other ✓✓fl Delta Depth of Grout Seal ®® Type of Grout l I Irrigation _.Approx, Depth I I Eastern Surface Seal installed Loy 0t&iind Repair Work Done 0 Type of Pumo,. H.P. State Work Done_ ;1$ Depth SealingMaterial i Depth ❑ Well Diarr Y � Depth :,"= L}' �� biller Naterial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other /1 Number of living units: Number of bedrooms V�J Character of Sol to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line ll DISPOSAL PONDS ❑ 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 cerlifies 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 sub-contracting signature certifisa 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 Californ ' The applicen st call for rt inspections. Com late drawing on rev r side. L� Signed X Title: Date: 0 DIEPARTMENT USE ONLY Application Accepted by Date Area 2 Pit or Grout Inspection by Date Final Inspection by ( 'r14 Additional Comments: I. f0 2 r Applicant - Return all copies to: San Joaquin County Public Qlalth Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFOAMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY _PATEPERMIT'No. . E 17.29 tREV, IAE EMN 1426 F I