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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � ENVIRONMENTAL HEALTH DIVISION 11 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT ESP I RES Y R M DATE S (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 cociplience with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. rr O/Job Address 2 1 W a-,s on A-tA� _ Cit. �G-tT.Q 4 Lot Size/Acreage 5/0- 4 97-7677 v"4wner's Name a.yl t 10f10 Contractor _,Eeo�2 Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well n 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 I-) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F.] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specification (� } f') PubliC Cl Other Fl Delta Depth of Grout Seal Type of Grout " I I laigaWn Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION INo septic system permitted if public sewer is ailable within 200 feet.) Inst tion will serve: Residence_ Commercial_ Other Number o ' 'ng units: Number of bedrooms Character of "A 1 th of 3 feet: ater table depth SEPTIC TANK. /Mfg Capacity No. Compartments PKG. TREATMENT PLT. Ll Method of Disposal Distance to nares . Well oundation Property Line LEACHING LINE ❑ No. a Length of line Totat length/size FILTER BED ❑ Distance to est: Well Founds Property Line SEEPAGE PITS ph Size Number SUMPS LI Dis Ince to nearest: Well Foundation Property Lin DISPOS NDS ❑ -Wwr'eby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordin es, state laws, and rules and regulations of the San Joaquin county Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issu 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 canities 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 Californls." Th applicant mu II f r all r n ons. Complete drawing on reverse side. C"' S Title: — CSC✓f?�r Date: —_ � T OR DEPARTMENT USE ONLY Application Accepted by Date < res Pit or Grout Inspection by Date Final Inspection by Dat' Z Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INF O AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE FERMIT'NO. :H13-24 IREV.„r s,