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f l APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P ❑ BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAJR FROM DATE ISSUED � (Complete in Triplicate) Applicatloa is hereby made to San Joaquin County for a permit to construct and/or install the mark herein described. This spplicatinn is stale in Corviisnce With San Joaquin County ordiaanoe No. 5119 and 1852 and the Rules and Regulations of San Joaquin County Public Sea.1tn Bervipee. i �. City�["j�_ Lot Size/Acreage Job Address - l Owne('s Name L'Aw Address Cvnuattvr Address � � Z-1 -' License No.�pr'Er Phare i TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service hell 0 L PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK!tSEWER LINES DISPOSAL FLO. I PROP. LINE FOUNDATION, ---_� AGRICULTURE WELL OTHER WELL ' PIT515U144PS INTENDER USE t', TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " C) Industrial 'I -;` ❑ Open Sotto rt Q Manteca' pia. of Well Excavation Dia. of Well Casing ° Rr60maatiCiPCIvato ❑ Gravel Pack+"T""L7 Tracy.'s ----'Type of Casing- 's Specifications r 1'1 Public f`1.Other %W r. :. f loolia- I Depth of Grout Seal ` Type of Grout I } f i Irripaoon Approx. Depth I I Eastern 5uriace-Seal installed by t . Repair Work Done ❑ Type o} Pump'l�_ HLP. --,� y4-_Y�F� State Work Done � lA Well Destruction ❑ Well Diameter scaling Material k Depth ] Filler Material A Depth . Depth � TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR1AOCIITlCN L I DESTRUCTION 1 1 INo Septic system permitted it public sews► is available within 204 feet.I �f InstellaWn will saws: Residence A Com►nercial— Other �! Number of living units: Number of bedrooms ✓ s; f Charactar of sod to a depth of 3 fiat: — --- _ Weter table depth SEPTIC TANK ❑ Typal.Mig Capacity No. Compamments Method at Disposal PKG. TREATMENT PLT.Cl i ', f r • ! s' �, _ __ _ T _. f .t......... ""..:... Distance to nearest: Well Foundation -Property Line Tf rt - LEACHING LINE CTotal lenth/wOl No. � Length of linea 9 ti FILTER SED 17 Distance to nearest: Well Foundation Property Line j - A SEEPAGE PITS 11 Depth r Size Number fit] SUMPS t.I Dlstanco toinaarost: Well Foundation _ Property Llne' a DISPOSAL PONDS ❑ I hereby Certify that I have prepared this application and that the work wifl be done in accordance with Sart Joaquin county ordinances, crate Laws, and (visa and regutataons of the San Joaquin county I 1 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 workmen's compensation laws of California." Contravtr's hiring or sob-contracting signature certifies the following: "I G„r'tlty that in the performance of the work for which this permit is issued, L shall employ persona tubject to workman's companso- tion laws of California." IM The applicant must cell for 411 raqwired insCtinns, Cornplare drawing on' aid S had Title: Date Z f R DEPARTMENT USE ONLY Application Accepted by Date �-' Area +1 y ,' PIt or Grout Inspection by Date Final Inspection by � Date Additional Comments: i Applicant - Return all rroples to: San Joriqula County Public Health Services k Environmental Health Permit/services r 44S H Sao Joaquin, P, O Box 2009, Stkn, CA 15201CK A ? FEE AMOUNT OUE i AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT N6. `! INFO . EH 17-tiSIrEV.r�npl IJ►f tL) r �j EH t4.7e {