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t APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENV I�rioXMENTAL HEALTH DIVISION ' 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 a PERMIT EXPIRES 1 YEAR-FROM DATE Ih ISUED (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. Job Address City S77eA.1 Lot Size Acreage Owner's Name- rde F/ L L I- Address sArrl - Phone 3/ 2- Contractor_ ,F'1-0YV E-. Address 7 A A 7— License No. ,: f( �e____Phone -3`2/ TYPE OF WELL/PUMP: NEW WELL ❑ r WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C1 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 * Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'] Public Ci Other fl Delta Depth of Grout Seal Type of Grout 1�} I I Irrigation —Approx. Depth I I Eastern Surface Seal installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Miler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION 111No septic system permitted if public sewer is available within 200 feet.) i Installation will serve: Residence ✓ Commercial Other , y i Number of living units: __.L._ Number of bedrooms y Character of soil to a depth of 3 feet: C L.A ____----Water table depth SEPTIC TANK. ❑ Type/M119 _ E X)ST/AJ& Capacity No. Compartments \� PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Pr operty Line LEACHING LINE or"No. 8 Length of lines /-leg Total length/sire /Bn FILTER BED �f ❑ Distance to nearest: Well * Foundation _ Property'Lins SEEPAGE PITS 141' Depth Size Number SUMPS LI Distance to nearest: Well Foundation 3 `� Property Lined Y - -x�- 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 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 towi of California." Contractor's 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 must call for all required inswtions. Complete drawing on reverse side-."" Signed X fes✓ Title: Date: 4OR REPARTMENT USE ONLY Application Accepted by 2 Date / Area Pit or Grout Inspection by Data f=inal Inspection by VMZAN& Dater `L- Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, O Bo 2009, Stkn, CA 95201 IFEE NF AMOU T DUE AMOUN RE ITTCK RECEIVED d E PERMIT'NO. . EH 1124(REV.665) lz� FH t/.36