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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 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YFAR FROM DATE IQSUED (Complete in Triplicate) Application is hereby made,to Ban Joaquin County for a permit to construct and/or install the work herein described. This application is made in cas>pliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County 1Public Health Jservices.I Job Address W fLd e, n• __„ City aCkLot Size/Acreage -54C�.t' -'-- Owner's NameCIC rE l Address 4_E�dk 46i Ci etlda &4-h In) Phone .57 3/f Contractor__ C�lsnv__pAddress License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR p 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing El Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1"1 Other n Delta Depth of Grout Seal Type of Grout . I I Irrigation —Approx. Depth I 1 Eastern Surface Ssal Initalled by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth � Depth Piller Material i Depth t1 TYPE OF SEPTIC WORK: NEW INSTAL LATI N EPAlRlApDITION A&DES7RUCT10No septic system permitted if public sewer is available within 20b feat,} Installation will serve: Residence� Commercial— Other Number of living units: _/ .Number of.bedrooms i t Character of soi<to a depth of 3 fest: ILQdA4& Water table depth �y SEPTIC TANK ❑ Type/IMfg t Capacity!2�06__ No, Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Z04 _ Foundation_--_-.� Property Line LEACHING LINE Cl No. & Length of lines O/7� f �v 9 Total PZ2:W. - FILTER BED ❑ Distance to nearest: Well f„l Foundation � ]�Proparty Line --lf�f SEEPAGE PITS 11 Depth _ <S —Size . � Numbere, SUMPS El Distance to nearest: Well-LAQG' Foundation-7� Property Lina DISPOSAL PONDS ❑ 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_signaturevertifies 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 workman's compensation laws of California.” Contractor's hiring or sub-contracting signature certifies the fopowinq: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss- tion laws of California," The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: 9oC y R D PARTMENT USE ONLY ApplicaWn Accepted by `/lA'�'-' Date 1 Area Pit or Grout Inspection by Date Final Inspection by fl.4t Data Ind 1p,� Additional Addional Comments: _ � �� .. l Applicant -'Return all copies to: San Joaquin County Public Health Services } Environmental Health Permit/Services t 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FFE i INFO AMOUNT DtIE7-� AMOUNT REMITTED C SH RfCEIVED BY DA PERMITNO. EH14-71 tREV. i e1 i© L! EH 11-30