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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f� ENVIRONWINTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 pEgUIT EXPIRES.- I YEAR ft9M DATE ISSUM (Complete in Triplicate) I Application Is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This 4 application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of.San # Joaquin County Public Health Services. Job Address C20 1-r q:g A/ gw y qc? - City&P IAA Lot Site/Acreage 9�2 Cr C k Owner's Name—75A kA ems— 2 S Ren Address U-2 Phone q& i "" �'Conttactorll,elf-t!�/ Rt-I:( u�r Address �,_ `�I (�7� � _License.'f�0. �-Phon t-�77 r TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well D PUMP INSTALLATION`f SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 I DISTANCE TO NEAREST: SEPTIC TANK._/00 SEWER LINES DISPOSAL FLD.iSO PROP. LINE 2_,L_ ; FOUNDATION AGRICULTURE WELLID_Ca— OTHER WELL PITS/SUMPS/-S:O INTENDED USE TYPE OF WELL PROBLEM AREA eTONSTRUCTION SPECIFICATIONS r f-1 Industrial ❑ Open Bottom ❑-Manteca Dia. of Well Exca tion Dia. of Well Cali g Domestic I Private Gravel Pack 0 Tracy Type of Casing P �` - _- Specifications M Public 1-1 Other 0 Delta Depth of Grout Seal- I T pe of Grout Ml Irrigation S .Appror. Depth ❑ Eastern 3 Surface Seal Instaliad by A i Repair Work Done U Type of Pump S_,2_1 H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material A Depth ; Depth Filler Material Z Depth = , i j: /".TYPE OF SEPTIC WORK: NEWINSTALLATIOND REPAIR/ADDITION Ll DESTRUCTION GI (No septic sy$ptT permitted if public sewer is 1 available within 200[aet.l^"_ , installation wili serve: Residence_ Commercial— Other ` , f Number of living units. Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK--4-y O Type/Mfg Capacity ? No. Compartments PKG. TREATMENT PLT. G1 t Method'of Disposal Distance to nearest: Well Foundation Property Line j f ' • LEACHING LINE' ❑, No. A Length of lines Total length/size FILTER BED (1 Distance to nearest: Welt Foundation Property Line SEEPAGE PITS "I I .Depth Sire Number r SUMPS LI Distance to neaiest: Well Foundation Property Line DISPOSAL PONDS ❑ - v :w 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 ` .. HOrtte owner or licensed agent's signature certifies the following: "i carlify that in the performance of the work for which this permit is issued, I shall not employ any person in,such manner as t0 become subject to workman's compensation laws of California." Contractof'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 subiect to workman's compensa- tion laws of California." • s , The applicant Must.call for all required inspaptionsil. Complete drawing on reverse side. ! / Title: j 7 �r` :� -. ._ Date: FqQ DEPARTMENT USE ONLY Applica ' n Accepted by pate 3 � Area Pit Gro spection b Date�^f f Final Inspection bye, Date l Additional Comments: Z f Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC-HEALTH SERVICES ENVIRONMENTAL HEALTH AIVISION 'PERNIT/SERVICES 1 995 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 �- FEE AMOUNT DUE AMOUNT-REMIT-(ED IiECEtVED 8Y DATE PERMII'N0, INFO CASH . EH13-24IREV.tin5) ^t� [ EH i4.26