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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 PERMIT EXPIRES 1 YEAR ROI[ DATE _SSUED (Complete in Triplicate) Application is hereby vme,to Sas 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. iJob Address l�� __'"' �� / f ✓� _ _ City Lot Size/Acreage Owner's Nameress, 4 7`��q G - r Z3 �j'' �., .._ Phone Contract / /6 � ' '.;`- _AdQress License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out 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 0 Industrial Cl Ogen Bottom ❑ Manteca Dia. of Well Excavation Dis. of Well Casing Cl Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public Cl Other F1 Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Dane U Type of Pump.„ -- H.P. _ State Work Dona_ Well Destruction O al Well Diameter Seing lfateriiL1 i&-Depth' --- - Z Depth Filler Mat i TYPE OF SEPTIC WORK; NEW INSTALLATION 1 I REPAIR/AODITIO 1 N l sy i if public sewer is � r�-j available within 29_Q fent Installation will serve: Residence_�#Commercial_ Other T11it may have expired WItIVU1 Number of living units: Number of bedrooms Character of soll to a depth of 3 feel: i being Gampiet%1 or inspected atto SEPTIC TANK: ❑ Type/Mfg 1y �js a PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE Ll No. 6 Length_ot._lines.. Totai,langth/size FILTER BED _ ❑ Distance to nearest: well Foundation Property Line SEEPAGE PITS I I Depth Size Number E SUMPS LI Distance to nearest: Wall Foundation Property Line DISPOSAL PONDS ❑ 4 tT- ~ I hereby certify that I have prepared this''pplication 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 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 1s issued, i shall employ persons subject to workman's compensa• i tion laws of Califomis." The applicant Call for a7r ,4d insn7s CC mple awing on reverse side. Signed A"'�t Title: Date: `j L FOR EPARTMENT USE ONLY G'� Application Accepted by date Z .� /� Area I Pk or Grout Inspection by Date Final Inspection by Date Ad>iltional_Commenu:-•-=- - Applicant - Return all copies to; San Joaquin County Public Health Service& ` - Environmental Health Permit/Services 445 N San Joaquin, vx 2009, Stkn, CA 95201 FEE INFO AMOUNT DtJE AMOU 7 REMITTED CASH COVE BY ATE PERMIT'NO.FF • EH 13-21(REV.v n sJt7 rpm/,^ , `� I Err 14•16 f, � -✓ ` `