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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 I IkERM T EXPIRES 1 YPR FROI[ DATE ISSUED (Complete in Triplicate) Application is hereby made to tSanJoaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 51+9 and 1$62 and the Rules and Regulations of San 4 Joaquin County Public Health Services. mob Address -jCx& AC, e /VJ d• City �L/� `� Lot Size/Acreage O , 6wner's Name r 4 Address Phone racts>r� �� S Address ':Z/2 9!a ! � 3 License NO.-71A07 ' Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR- ❑ OTHER O 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 0 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private . ❑ Gravel Pack* Tracy Type of Casing_ Specifications I'I Public Ell-1 Other i 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation q ' ro — pprox: Depth I I Eastern Surface Seal Installed by Repair Work Done .0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material-&:Depth - a Depth Tiller Material & Depth f� - hv TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODITION•I 1 DESTRUCTION INo septic syslem permitted if public se ' ¢ - vailable within 200 feet.! Installs I serve: Residence Commarcia! _' Other _� - �., "^'- Number of living Number of bedrooms ,_ `-- Character of soil to a depth t: t ater table depth SEPTIC TANK' ❑ Ty pa/Mig �4 $ Capacity No. Compartments PKG. TREATMENT PLT.'O `t Z i Method of Disposal Distance to nearest: Well undation property Line t LEACHING LINE ❑ No. & Length of li rel lengthlsize FILTER BED ❑ Distance rest: Well Foundation rty Line SEEPAGE PITS I Depth I Size Number,, SUMPS Ll Distance to nearest; Well Foundation p o r' D!S L PONDS ❑ j !perry Lina -�y� hereby certify that ! have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, atala laws, and 1 rules and regulations of the San Joaquin County,,• t,--w -- - _z Home owner or licensed agent's is ag signature Certifies the following: "i certify that in the perfoimance.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'llaws of California."'Contrector's-hiring or subcontracting 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 st call aB required tions.Complete drawing on rev side. Signed X-4 lok�w_ Title: A/1 Oats: fDEPARTMENT USE ONLY Application Accepted byArea -� Date — 6 Pit or Grout Inspection by Date nspectiondWy a a ' Final Iby Date 3 G a Additional Comments: r 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 FEE AMOUNT DUE AMOUNT REMITTED CK `°e 0 RECEIVED B_1. INFO CASH DATE PERMIT-NO. EH 13-24• Ell 14-29 .t/e31 , S 3�-t�-q� 73 --� S �.