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�* APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIMTAL' HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE S (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 Bervi es. I Job Address 6�4 - City1..et Size/Acreage r A t4f Owner't Name D Phone Contractor © �®�C 1 �� License No. ICI`� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 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 USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17:1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 11 Other fl Delta Depth of Grout Seal of Grout I i Irrioation Approx. Depte I I E stern J�cs Seai nstalled by Repair Work Done of Pump H.P. State Work pone Well Destruction ❑ Well Diameter Sealing Material i Depth? Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of riving units: Num of bedrooms ' Character of acid to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Ca ity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Il ;F ',ndattion Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth :e Number SUMPS LI Distance to neatest: Well Foundaa Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in acc -dance with San Joaquin county ordinances, state laws, and rules and regulations of th an Joaquin County Homo owner or licm agent signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any perso such manpr as to become subject to rkman's compensation laws of California," Contractor's hiring or sub-contracting signature certifies-the fol ng: "I cern hat in the pert a o work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lawn of ifomia.' The appiica mu r requir ns wing on side. Signed}L _.. Title: ✓ Date: r / � FOR DEPARTMENT USE ONLY Application Accepted by Date .19 Ares 2 1C rel' Pit or Grout Inspection by Date Final Inspection by Data S Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RE EfVI2D BY DATE PERMIT NO, EH 13.24 iREV.Iy"Sr EH 11.16 ..r