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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 4 #445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES _1 _YEAR- FROM DATE ISSUED ( (Complete in Triplicate) Application is hereby ma44e to San Joaquin County for s permit to construct and/or install the work herein described. This application is made is catpliance.:xith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. -n Job Address 07-2 AL [fL (PK aCity- _ ,( f a'pl Lot Size/Acreage ,[ Awn � Owner's Name Wi Address r�`� ��_ �i a _ Phone . E Contractor /r elf I )`� E I dress 31l J License No. Phone ` TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHEN ❑ 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 L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public 1-1 Other f-1 Delta Depth of Grout Seat Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done XJLR Well Destruction �"" Well Diameter F- Sealing Material i Depth h Depthtiller Material i Depth y TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I l DESTRUCTION I I tNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of sols to a depth of 3 feet: t Water table depth ^ SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal D-++stance to nearest: Well foundation Property Line ' ,LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to'nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Si le Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 licensod agent's iignaturelcsrtifies 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 certify 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." The applicant II for ad requO41rnspoptions. Complete drawing on rev r side. q. 1 Signed Title: O��f, Date: _ R MENT USE ONLY n� Application Accepted by CR r16 Date "' Area C� Pit or Grout Inspection by Date Final Inspection b Datr� iP Additional Comments: .e Applicant - Return-all copiest to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stirn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMiT'NO. INFO CASH Ek 3-24• EN 1ta�eREV.fiK51# / . f 6 ef 23a