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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_"IRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby msec to San Joaquin County for a permit to construct and/or install the work herein described. This application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. L/Job Address City Lot Size/Acreage {/Owner's Name P� �l�"•r�'P�/O Address orI� G'GG1s7�f Contractor ess^^ License W. Phone Z TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ? C} Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ " Specifications 1'1 Public 1.7 Other Cl Delta Depth of Grout Seal Type of Grout O I I Irrigation _Approx. Depth I 1 Eastern Surface Seal Instatied by Repair Work Done U Type of Pump H.P. State.Work Done— 1� Well Destruction O Well Diameter Sealing Material i.Depth Depth Filler Material i Depth OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 13 DESTRUCTION lNo septic syste road it public sewer is available wi teat.} �J Installation will serve: Commercial Other Number of living units: Number come Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ' ❑ Type/MfgCapacity No, Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: WellFoundation roperty Line LEACHING LINE ❑ No. m Length nes Total length/size FILTER BED ❑ Dista o nearest: Well Foundation Property Line " r SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISP L PONDS ❑ I sreby 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 workman's compensation taws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work_for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." ' /T "°applicant s 11 for rrsquuired ins , tions. Complete drawing on reverse side. V Signed X' Title: _t1��1/p/-' Date: 1_ OR DEPARTMENT USE ONLY &4,Application Accepted by V11� - 1�3. _• Date �' Area Pit or Grout Inspection by Date . Final Inspection bye~ `Date 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 �JAMOUNT DUE AMOUNT REMITTED ,•' CK RECEIVED BY DATE PERMM/IT•NOO... . 21 TREY.r i w 5! rN 13- h� Ek 142e