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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 PERMIT EXPIRES I YEAR FROM DATE S (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 ccmiliance with Sea Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San I Joaquin county Public Health Services. i Job Address *ter eC i City' Lot Size/Acreage �''1 Owner's Name p L[ L L�#- §ddress a� �C`� f23—"a-1 1 r I Contractor &'IIs l r Address License No. Z Phone�22 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT F7 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TAN _/hte t+,L�4 ER LINES 9 SAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL t,�OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS iP ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing tP40mestic/Private Gravel Pack ❑ Tracy Type of Casing___J?i/C Specifications f'1 Public rZ Other. Tl Delta Depth of Grout Seal ® Type of Grout /� f v I I Irrigation Ax. Depth I I Eastern Surface Seal installed by L Repair Work Done Q Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) -Installation will serve: Residence= Commercial_""Other - Number of living units: Number of bedrooms Character of sod to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT.Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ci No. el', Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS I 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 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 shad 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 shall employ persons subject to workman's compensa- ton Iowa of California." Signed mp �� The applicant/ st call for so required ' tions. Complete drawing on reverse side. S' ned x,l La✓ i Title: _ +e r`I�� --- --- Date: - FOR DEPARTMENT USE ONLY L A / Date Area Application Accepted a pPl eP b D Y :3 Pit or rout spection by IZIPI Date Final Inspection by Data Additional Comments: Applicant - Retur` 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 RECEIVED BY DATE PERMIT'NO. ?�.] INFO CASH B�7 CASH 11 . EH 13-24 1REY.1/$151 1VW g v�,r i 0 3372 EH 14.26