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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 O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED (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 cosipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations or San Joaquin County Public Health Services. 1 Job Address - aA o e,-,i &T(9-- City 40IW Lot Size/Acreage !!k22 Owner's Name Address Phone f Contractorct Address �C�a. License No• Phone c3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ j PUMP INSTALLATION ❑ - SYSTEM AEPAIR-0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Battom ❑ Manteca Dia. of Weil`Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'I Public 1"1 Other f1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done t Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth { TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.! {� Installation will serve: Residence_ CommerciapT__ Other + !Number of living units: JCL Number o1 rooms C5 Chiracter of loll to a depth of 3 feet: of Water table depth j .SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments > ' PKG. TREATMENT PLT.❑ / Method of Disposal Distance to nearest: We11 r<0 Foundation�— Property Line UDU LEACHING LINE I# No. i Length of lines 1 Total.length/size � J FILTER BED ❑ Distance to nearest:- Well-f F�6L— Foundation Q'I -Property Lina ? 1 SEEPAGE PITS $t" DepthSite Number-- ,�y� I SUMPS LI Distance to nearest: Well Foundation 11 Property Lina CTIO 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 signature certifies 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 work sfocompensation laws of California." Contractor's hiring or sub-contracting signature i certifies the following: "I certify that in the performance of thew r which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant t Cail fpr all regI ins tions. Co ate drawing on reverse side. Q Sig Title: _ Date: _c�� , FOR DEPARTMENT USE ONLY Application Accepted by Date S Area Zq Pit of Gout'Inspection by � Date Final Inspection by i Data Additional Comments: ✓ ? r IP W �' GG r OrK y 50 r u of r!]rpt� Applicant - Return all copies to: San Joaquin County Public Health ServicesO"ujr/NtDr'�CD1 r+97�1r� 461e tag_5 Environmental Health Permit/Services �r K 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE Md` INFO AMOUNT DUE AMOUNT REMITTED CK 0 GASH �RECEIVED BY DATE PERMIT•NO. . EH 13.21 IREV,r�n51fl/ '7J $ E04 14-M i ( 4 l c/ i 4-