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v* APPLICATION FOR PERM I T JOAQUIN COUNTY PUBLIC HEALTH SERVICES .�" ,4�' l� ENV I RONICKNTAL HEALTH DIVISION 445 N SAN JOAQUIN r PHONE (209)468-3420 C1 b P 0 BOX 2009, STOCKTON, CA 95201 ,0%' PERMIT EXPIRES 1 YEAR_ FROM„DATE ISSUED i 1�v (Complete in Triplicate) Application: is hereby made:to San Jbaquin!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 Services. Job Address �` / //`f�?C/ City s� Lot Sizt/Acreage Owner's Name Addresses Phone Contractor LAL Address 3LO License No.�L Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L3 DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES DISPOSAL FLD. PROP. LINE FOUNDATION _{AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO_LEM AREA I CONSTRUCTION SPECIFICATIONS L1 Industrial i ` ❑ Open Bottom, ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public n Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation __ Approx. Depth I I Eastern ,Surface Seal Installed by Q Repair Work Done LJ Type ofJaump f H.P. ' _ State Work Done r Sealing Material i Depth Well Destruction`""'❑'-'�Welt'Dia795PCer ``'""" 5 : a :(Depth ! l Filler Material & Depth% TYPE OF SEPTIC WORK:. NEW INSTALLATION l I REPAIRIADDITION RUCTION I 1 lNo septic system permitted if public sewer is �- available within 200 feet.) Installation will serve: Resi nce I�Corhmercial_ Other t Number of liviriq units::==1�7urnbe of bedroo s Character of soli to a depth of 3+feet: _- -Water-table depth SEPTIC-TANKb 0 TypelMfg ) Capacity No. Compartments PKG.,TREATMENT PLT. Gl "'"�" '"�'"¢"""" Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Lam:8 Length of lines T al length/size -FILTER BED ❑ -Distance to nearest: Well Foundation_ �."� Property Line SEEPAGE PITS I I Dep`tl Size Number ' SUMPS} v tstance to riaarist: Well Foundation ! Property Line s 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 workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I cartity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." t s The a t I r all aqui i c ' ns. Complete drawing on r verse sid . I r lk2 Signed Title: . Date: € ` 'F DEPARTMENT USE ONLY Application Accepted by - ate` , oma. Date �� _C1 Area ? f i , Pit or Grout ins tan b - Date Final In Pec y pection by ata Additional Comments: + Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, + EH 13.24 IREV.tin 5) EM 1426