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APPLICATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ` EMT EXPIRE 1 !tEAR 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 is compliance with San Joaquin County Ordinance No. 549.and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. n / Job Address City E��--� .�3A✓Lot Size/Acreage 1 �/Li ► t '� X17 °� ^ Phone' Owner's Name r } `e Address J ; f* 7Z {ct � f Address 1� License No. Z Z Phone Contractor — ervice Well 0 TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT L I DESTRUCTION D Out Monitoring Well ❑ ,PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O k DISTANCE TO NEAREST: SEPTIC TANK y SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION # AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑-Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private Type of Casin❑ Gravel Pack ❑ Tracy g SpecificationsType of Grout. — -- i'l Public n.other C1 Delta Depth of Grout Seal 1 1 Irrigation —Approx. Depth l I Eastern f Surface Seal Installed by r Repair Work Done U Type of Pump H.P. State Work Done �..- sealing Material i Depth Wolf Destruction ❑ Well Diameter Lr Depth Piller Nater ial,Ii Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRlADDITION i I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) f Installation will serve: Residence 4 Commercial_ Other Number of living units: Number of tasdr ms Character of Sam to a depth of 3 feet: E tti Water table depth SEPTIC TANK. ❑ 'Type/M11 Cr Capacity(.. .- No. Compartments 17 .� . PKG. TREATMENT PLT. ❑ r _ r Method of flispoaalf Distance to nearest: Well Foundation Property Line—9 �ID � 0 ` LEACHING, LINE Ll No. 6 Length of lines i17� -� Total length/size i FILTER BED ❑ Distance to nearest: Wali Founaagon Property�Une — { SEEPAGE PITS I'I Depth �� %Size _ ' C 'Number `7 SUMPS l Distance to nearest: Well / " Foundation� Property Line��0- - DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will ba done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sen 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, 1 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 is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The a icant must Cal or all requir ins =fioninpleis drawing an r versa ids. . I Sigma Title: j Z ? Date: i r �F R DEPARTMENT USE ONLY 1 Application Accepted by Date ren Pit or Grout Inspection by Date Final inspection by to 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, Stltn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. INFO ll / . EH 13.24 111Ev.r,sssl r f7 f7 CPO 58 l IH C-72- c12- ' EH 14-26