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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 ERMIT EXPIRES I YE FR M DATE S (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coagalance vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 'Job Address 39 14 I City Lot Size/Acreage Owner's Name - Address Phone 311�110 Contract Address .�o o/ License No. 2ezz Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ - DISTANCE TO NEAREST: SEPTIC TANK z SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL,.,, PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial . ❑ Open Bottom '' ❑ Manteca.; Die. of Well Excavation Dia. of Well Caairig � Cl Domestic/Private ❑ Gravel Pack. t ❑ Tracy --;-'Type of Casing_ Specifications 11 Public Ci Other n Delta-/ {� r Depth of Grout Seal Type of Grout I I Irrigation _.Appro><. Depth I (,.Eastern 5 Surface Seal installed by 1 Repair Work pone 0.,-`Type of Pump + H.P.. -''�� State Work Done Well Destruction ❑ .Well Diameter "' r Sealing Material rls Depth Depth = ]w'ilie'r Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I-).L REPAIR A-DDITIOhP<�6ESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will sem: `Residence--L-11'Commerctal'-1- that Number of living units: + Number of rooms .Character of will to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg f Capacity No. Compartments PKG. TREATMENT PLT, ❑ �: Method of Disposal Distance to neaiest: -2 Wel---� Foundation Property Line LEACHING LINE No. & Lengthof lines '6— ''` Tgtat length/size X j FILTER BED ❑ Distance lo,nearest: /Wall 5'± Foundation T�r) + Property Line SEEPAGE PITS ,> Depth / � Sire umber / SUMPS ul Distance to nearest: Well Fou t Property - Lina DISPOSAL PONDS ❑ - I hereby certify that t 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 sigriature oe.nifies the.tollowing::Lcertify-that-inlhe.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 } cerlifies the following: "I certify-that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compansa- tion laws of Californle." X" The applicant t call for' fired inspections. Complete drawing on reverse side L 6 Signed / Titl6: Date• "FOR DEPARTM-ENT"US"E ONLY aApplication Aoceptad.by. -= Date 4 Area -21 flit or Grout Inspection by Date Final Inspection by Date - p� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services 1 Ebvironmental-Hdel'th'Permit/Services 445 N San Joaquin, O Bos 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. s EN14-241REV.t/N41 EM 14.76 I 67 93—o9 rr I ' v T 7