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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. 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE I __UkQ (Complete in Triplicate) Application is hereby made to Sap Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance trith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. // / Job Address (�(/'tLf� / ,o — 4-040 City Ld Lot Si ze/Acreage ! '61 C . Owner's Name _Tkis6) O Address phone Contractor )4C— Address —License No.30S71�/ _Phone r3696d v TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER O Monitoring well L3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing EI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ['1 Public 177 Other fl Delta Depth of Grout Seal Type of Grout r I ! Irrigation Approx. Depth I I Eastern Surface Seal Installod by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I lNo septic system permitted if public sewer is f available within 200 feet.) Installation will some: ResiQence Commercial_ Other Number of living units: 1 Number of bedrooms Character of&A to a depth of 3 fast: Water table depth �d l SEPTIC TANK. 0 ,Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ - =- --- - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L�No. A Length of lines r � Total length/size FILTER BED 0 Distance to nearest. Well _ Foundation d Property Line SEEPAGE PITS ft'h'Depth 2 S Size �� 'Number SUMPS LI Distance to nearest: Well 0 ► Foundation �-[� I Property Line 40 1 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 Homs 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 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 applica t must II for I raquir n t' s. Connplate drawing on reverse side. Signed Title: Q�� 0-e-- C B 3 Data: FOR DEPARTMENT USE ONLY Application Accepted by Date17 _ 3 Area --�,- Z_ 1 N " or Grout Inspection b al InspectionD by Additi,nal Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, ox 2009, Stkn, CA 95201 FEE AMOUNT 01JE AMOUNT REMITT INFO ED K RECEIVED BY DATE PERMIT'NO. r EN 13.24(tali.r 1115) 1 EH 14-m