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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I . ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 i P 0 BOX 2009, STOCKTON, CA 95201- PERMIT 5201PERMIT 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Serviddeess., Job Address 2 3 f � �� City Lot Siae/Acr 7eage ,�} Owner's Name �JP1'L/Ilo!e� J'J ! Address � Phone �'�"' ��a✓ t Contrattor + Address .1�_4 License N.—�36S F1 Phone TYPE Of WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR © OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl DomesticlPrivate C1 Gravel Peck I 0 Tracy Type of Casing_. Specifications I'1 Public 0Olher n Delta Depth of Grout Seal Type of Grout 1 1 Irrigation _Approx. Depth I I Eastern Surface Soul Installed by Repair Work Dane 0 Type of Pump i H.P. State Work Done Well Destruction ❑ Well Diameterscaling Material i Depth [� Depth Tiller Material i Depth f t 0J i TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) k Installation will serve: Residence— Commercial Other C--- 'AA-t,?� P Number of living units, Number of bedrooms - Character of soil to a depth of 3 feat: ' _ r Water table depth l� SEPTIC TANK. e'Type/Mfg J,.., C_ Capacity No. Compartments l PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well FoundatPn__ L_� Property Line t LEACHING LINE Gi/No. 8 Len®th of•lines 5162r Total iengthJsixe � FILTER BED FY Distance to Q raft: Wall Foundation Property Line t SEEPAGE PITS wl!Depth a 5 / -Size r� Number SUMPS LI Distance to nearest: Well d r ` Foundation / r a �,..� Property Lina � DISPOSAL PONDS ❑-1 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 signature 6e'rfifies the following: 1 comity that in the'periormance of the work for which this permit is issued, I shall not employ any person in such manner as to-bac, m, subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the periormanca of the work for which this'permit is issued, I shalt employ persons subject to workman's compensa- tion laws of California." s.) ' IL The applie277", or rill"r uir inspgctlons. Complete drawing on reverse side. 2 Signed Title: r� Date: / R DEPARTMENT USE ONLY Application Accepted eP by,.---'..- FOR Date 'f3 Area PIR or Grout Inspection by pate Fin I Impaction y Dae 2� Additional Comments": Applicant - Return all copies tp: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin,-P O Box 2009, Stkn, CA 95201 f FEE AMOUNT DUE AMOUNT REMiTTEO /IlECEIVE BY D TE PERMIT'NO. 1 INFO . EH 1314 4 24 IREV.l i e Si /I' ,f r_40-0 f11 u•te i