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s i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENNTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 XM 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Cyan Joaquin County Public Health Services. -t- Job Address City Got Size/Acreage r < _ - Owner's Name ! Address Phone Contractor ddress 42494 License Na. Ll Phone z TYPE OF WELL/PUMP: NEW WELLK WELL REPLACEMENT n DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. '"_ PROP. LINE FOUNDATION , - r AGRICULTURE WELL OTHER WELL � PITS/SUMPS e n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y� ` Ci Industrial O Open Bottom 0 Manteca Dia. of Welk Excavation Dia. of Well Casing .✓�� Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ Specification.. l'I Public f:l Other n Delta Depth of Grout Seal - Zle_ Type of Groin /2-61� I I Irrigation 07OApprax. Depth I I Eastern Surface Seal Installed by, OM Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction 0 Well Diameter Sealing Material i Depth � Depth (Tiller Material i Depth �t TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is R\ >1 available within 200 feet.! Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soN to&'depth of 3 feet: Water table depth f SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKd:-TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line ZN LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BLED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 1 I Depth Size Number SUMPS LI Distance to nearest: Well Foundation . Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared'this application and that the work will be dome in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Horns owner or licensed agent's signature canities the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any parson in such manner as to become subject to workman's compensation laws 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 CalNornt&." The applican u fdr 1tions. Complete drawing on r v e side. Sigr,� Title: Date: OR DEPARTMENT USE 04. Applicat Accepted by Date �7'� Areay L Pit or rou Inspection by� .v-�1�Date�— final Inspection by�y ��• =:s __ Date�� L r . Additkmat 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 FEE AMOUNT DUE AMOUNT REMITTED CK' RECEIVED 83- O TE PERMIT'NO. ' INFN p r CASH . EH 13-24 IREV.t/R 61 A/ EH 14-0e A t 111