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E APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR R M DATE (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 catspliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job ] Address :Z b City _ Lot Size/Acreage Owner's Name �►CLLL I Ir/L�h�ar' Address S Q fill'e Phone Contractor �es1g dress _y� J �� e�/ License No. ��L Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Dut of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public r1 Other Cl Delta Depth of Grout Seal Type of Grout I i Irrigation _Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth r'- t Depth } Filler Material i Depth ! �rl� r / tr.lit r�J TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION 11 ANo se tic SVIII'lem4ormilled if public sewer is available within 200 feat.l Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms ' Character of still to a depth of 3 fest: Water table depth <1 SEPTIC TANK. 0 Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines __ Total length/sire 7" FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 tete 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$hall 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, I"H employ persons subject to workman's compensa- tion laws of California." The applicant call for all required inspections. Complete drawing on rellise side. p 7 p Signed X .!� L/ n� Title: L ,L�l/A Date: t FOR DEPARTMENT USE ONLY Application Accepted by ` Date Area ` Pit or Grout Inspection by Date Final Inspection b Date 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 INFO FEE /AMOUN/T DUE AMOUNT REMITTED j�CA/SH RECEIVED BY DAAT�E,/ PERMIT'NO. . EH 13.24(REV.i I m s EM 14•1111