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I APPLICATION FOR PERMIT .�► SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION n 445 N SAN JOAQUIN, PHONE (209)468-3420 � P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR R D (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 is Md* is cos4t116nce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Putlic Health Services. Job Address �/c�D S� , ! a _ Wt Size/Acreage Owner's Name �t ' Address Phone �! �L IL Contratto( AddressLicense No. )6 V Phone r/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Cl Out of Service well L1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 1.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications I"I Public Cl Other n Delta Depth of Grout Seat Type of Grout I I Irrigation _Approx. Depth l I Eastern Surface Seal Instailad by Repair Work Done U Type of Pump H.P. State Work Done , Well Destruction ❑ Well Diameter Sealing Material Doh Depth Tiller Material ./Depth TYPE OF SEPTIC WORM: NEW INSTALLATION ! 1 REPAIR/ADDIT+ON DESTRUCTION 1 ) INo septic system permitted it public sewer is available within 240 feet.) �nslallation wtll Larva: Residence— Commercial— Other Number of living units: Number of bedrooms R Character of Intl to a depth of 3 hat:_ Water table depth f�"J SEPTIC TANK ❑ Type/Mig Capacity No. Companntents PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation — Property Line — � r LEACHING LINE Cl No. & Length of lines ,r _ Total length/size FILTER BED ❑ Distance to nearest: Well - tc)r - Foundation Property Li SEEPAGE PITS 11 Depth Size Number_ SUMPS Ll Distance to neamst: Well Foundation 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, stats laws, and rules Ind regulations of the Sten Joagvin County Homs owner or licensed agent's signature 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'&compensation laws of California." Contractor's hiring or sub-contracting signstwe certifies the foNowing: "I certify tftaf in the performance of the work for which this permit is issued, I chap employ persons subject to workow's contpww- tion laws of California." The applicant"Luer calf for irad inapecti s. Complete drawing on reverse side. Signed !P� Title: Date: l/� FOR DEPARTMENT USE ONLY , Application Accepted by Data e Ar ==---- -- Ph or Grout Impaction by Date Final Inspection by Date Additional Comments: Applicant - Return all copiep to: San Joaquin County Public Health Services Environmental Health Permit/Services /� !� 445 N San Joaquin, P O Box 2009, Stkn, CA 9520 1r f dDD�/ INFO AMOUNT OUE AMOUNT REMITTED CK RECEIVED!s3- DATE LJ PERMIT'NO. f . 2t,13-24 UIEv.t,rr tLIZ71 i:�V /V EH 14,96 i