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i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 iP 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 -ILEAR 1-YEARFROM DATE P (Complete in Triplicate) Application is hereby made•to Sin;Joaquin County for a, permit to construct and/or install the work herein described. This mp application is made in coliance;with San Joaquin county Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. t _ Cit Lot Size/Acreage Job Address 1/�� - f ! ` Address Phone Owner's Name f/4 t nim � ` Address � LicelQo. � Phone '- Contractor — TYPE OF WELL UM ,NEW.WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service well ❑ F OTHER ❑ Monitoring well ❑ PUMP INSTALLATION ❑* SYSTEM REPAIR '4 DISTANCE TO NEAREST: SEPTIC TANK - '- ' SEWER LINES" R —DISPOSAL-FLD. . '—"- �PROPvLINE-- - �- - FOUNDATION AGRICULTURE WELL OTHER WELL— INTENDED r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ --6 Dia. of Well Casing �1 DomsaticlPrivate ❑ Gravel Pack n Tracy Type of Casing_ :1 Specifications. -- I'1 Public I"1 Other .I 171 Delta Depth of Grout Seal Type of Grout I I Ifrigation —Approx. Depth I I Eastern Surface Seal Installed bj E Repair Work Done Type of Pump,. H•P i tat4 Wor Done Well Destruction ❑ Well Diameter Sealing lfaterial k Depth Depth Piller Material i DepthAj TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUC ION-1 1-availseptic system ermi led if public sewer is \ t feet Installation will serve: Residence_.._ Commercial_ Other _ Number of Rving-units: Number of bedrooms Character of SON to s depth of 3 feet: I - - -: Water table depth . SEPTiC TANK ❑ Type/Mfg f Capacity Nw- � � , PKG. TREATMENT PLT.Ll Distance to nearest: r Well foundation PropehMZ Y�rulltp LEACHING LINE L"1 No. 6 Length of linea Total len tFi T FILTER BED 0 Distance to nearest: Well Foundation �EN �V�+I NTAI.H�A�11�471v I, SEEPAGE PITS I i Depth Size Number SUMPS - LI—Distance-to nearest: Well _ Foundation~" Property Line 44 DISPOSAL PONDS ❑ k' 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 ffffff rules and regulations of the San Joaquin County Home owner of 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 amploy 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:111 certify that in the performance of the work for which this permit is issued,I shall employRorsons subject to workman's compensa- tion laws of California.,, The applicant at Coll for required inspections. Complete drawing on rearse side. l `/n,o-c.d Date: r Signed X Title: FO EPARTM Application Accepted by Date `� Are& Pit or Grout inspection by Date Final Inspection b a �Dets` Additional Comments: I r Applicant - Return all copies to: San Joaquin County Public Health Services 8nvironmental Health Permit/$ervices 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 FEE AMOUNT DUE' AM UNT REMITTED ArCK a I RECEIVED BY D E PERMIT N0. 0 k a EM 1124 MEV.r/e5l /� l EH 14.25