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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 ISSUBP (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application In made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health a� lice''s.fW Job Address 1� � ,. L _ City Lot size/Acreage -� l�-'�'"1` �,• L� �z/n� 5�9a (�� n Owner's Name Address � � , ,_ Phone Contract li " , Address��U� _I 22(0 (o -5 10 -- License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USf TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' r.. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation' V of 19 EI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ 3 ` I'1 Public f-1 Other C1 Delta Depth of Grout Seal I 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by AW .11 Repair Work Done IJ Type of Pump H.P. State Work Done, Well Destruction 0 Well Diameter Sealing Material i Depth t..C�a Depth list Material i Depth 011 S R� ,30".4 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/A DITio DESTRUCTION (Nosept retitled if public sewer is availab�fe within 200 few,I Installation will serve: Residence- Commercial_ Other Number of living unity: Number of rr Character of sol to a depth of 3 feet: '\ Water table depth SEPTIC TANK. J� Type/Mfg '�f' Capacity` No. Compartments PKG. TREATMENT PLT.❑ i / Method of Disposal Distance to nearest: Wall Foundation 0 Property Line _ / r i LEACHING LINE No. 6 Length of lines' - ` Total length/size FILTER BED 0 Distance to nearest: Well sC� � Foundation A0 �_ Property Line SEEPAGE PITS Depth ��t _Size Nymber SUMPS L1—.Distance to nearest: Well Foundation -Property Line SL DISPOSAL PONDS ❑ t 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 nature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell 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 pert ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion taws of California." The applicant must II for all uireoinspections. Complete drawing on reverse si e. Signed 1 1 Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byOA2 a ats l Area Pit or Grout Inspection by Date Final Inapec' nby Date�W Additional Comments: Applicant - Return all copies to: San Joaquin Co my Public ealth Services Environmental Health Permit/Services 445 N San Joaquin, Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. • EM 1]•24JREV.,in6),�4 /1'.t-C� // � `/