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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) 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services�. j� f Job Address Z l C►—yt3U e City 1 Lot Size/AcreageSlog -q1S_S_ Owner's Name e tf f/f1 Q /1 (Lt WAAddress Contractor IL Address Fir 0 . 7 -&ZT_License Noc'_,kgg3 93 Phone3 7 TYPE OF WELL/PUMP: NEW WELL ❑ '"WELL REPLACEMENT>A- DESTRUCTION- Out-of-Service-Hell PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring rWell ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE' TYPE OF*ELL PROBLEM AREA CONSTRUCTION SPECIFICATI S L1 Industrial XOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing��. r Specifications Il Public 1-1 Other Cl Delta Depth of Grout Seal lin Typo) total.- rmrn I.I Irrigation _Approx. Dap h 1 Eastern Surface Seal Installed bytZ � t Repair Work Done L] Type of Pump .�., H,P. ate Work Wall Destruction Well Diameter da Sealing Material i Depth 04s,^ t7 . Depth 'f Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 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&oil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of linea — __-_ ____ - --__ __-_.-_-_- Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS - _` __L]. Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt 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 is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all r uk inspections. Complete drawing on reverse aLee Seg Title: < rDate:qlWe.�-L i TR DJ PARTMENT USE ONLY q � Application Accepted by / Date !— Area t 12 Pit or Grout Inspection by Date Final Inspection byDlata Additional Comments: -, d tNag, t . o?I Applicant - Return I1 cop to. San Joaquin County Public Health Services p/d JUUP(f 'J Environmental Health Permit/Services /^6� 445 X San Joaquin, P O Bax 2009, StXn, CA 95201CK A R&91`o4_1 AMOUNT REMITTED CASH RECEIVED BY DATE ERMIT'NO. . EH1344(REV.iiR31 �t/ � f � r EH 14Ie