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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_ FROM DATE ISSUED .. (Complete in Triplicate) F 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 San Joaquin County Public Health Serv1des. �(Job AddressZ 7' ®aQ�`> 5� City �A�✓4'1 Lot Size/Acreage yes , X Owner's Name &4e �� Address Phone 5� �5 o0 �� X Contractor^ Address ;r V ;50)C ��D _ License No.S- �g��r Phone TYPE OF WELL/PUMP:, NEW WELL 0 WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ i DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca ,Dia. of Well Excavation Die. of Well Casing yp Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I» I'1 Public Cl Other (l Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work.Done U Type of Pump I H.P. State Work Done_ Well Destruction ❑ Well Diameter 'F Sealing Material A Depth Depth 1 Tiller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I ! DESTRUCTION I I INo septic system permitted if public sewer is Iavailable within 200 feet.] Installation will serve: Residence - Commercial— Other_��nrtie�� f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 04 SEPTIC TANK. O TypelMfgCapacity JIRD No. Compartments Zii PKG. TREATMENT PLT.❑ , Method of Disposal �s .Distance to nearest: Well 31 Foundation ID Property Line LEACHING LINE No. & Length*Of lines 0 Tgtal length/size Z FILTER BED 0 Distance to nearest: Well 25(5Foundation.— - Property Line- r©r _ t m SEEPAGE PITS 161--Depth2ALM Sire SUMPS Ll Distance to rtesrast: Well 306 Foundation i _ Property Line fC70 DISPOSAL PONDS O ° 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 shall note employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring Or sub-contracting signatures certifies the following: "I certify that in the performance of-.tho work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The oppiic must all for an iir spec' ns. Complete drawing on r rse'side. signed Title + -� _ _., Date: l(] 7 r\ rya a [`� K • �; y i kF R DEPARTMENT USE ONLY f k - n-7 Applicationt � Application Accepted by Data r 7-9z—Arse Pit or(trout Inspection by Date Final Inspection by Date 6�aZ �j m Additional Cormiments, AAV / } Applicant -`Return all cokes fto: San Joaquin County Public Health Services— «. Environmental Health Permit/Services eel �. r.. "r Et 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201.FEE _ a a INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED 9Y DATE PERM17'NO. l r . EH Z�tRVri sr VZ �pf r t14LU lEr � rO� p L