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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 PEMIT R IRES 1-YEAR 1-YEARFROM DATE (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services., Job Address , City Lot Size/Acreage Owner's Name J Address Phono ze Contra tlor el ddress �-� .�G� �7�g�//� phone License No._ ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ . SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dis. of Well Casing Cl Domestic/Private LI�Gravel Pack,-. t. ❑ Tracy� *�Type�01-�Casing-- S Specifications �ublic 1-1 Other rl Delta '"Deptli of Grout_Seas #, '� a Tips of Grout G I l Irrigation —Approx. Depth I I Eastern Surface Seal Installsd Repair Work Done U Type of Pump -• H.P. T State Work Done _ Well Destruction O Well Diameter 8ealini3 Material i Depth Depth T111er�Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION [ I DESTRUCTION I I (No sepiic.system permitted if public sewer is r ;- 4^lintillation will serve: Residence _ Other ' -thin`ZOD'f t'1 Commercial Number of living units: Number of bedrooms Character of NA to a depth of 3 test- Water-table deg;h}- 1 SEPTIC TANK. ❑ Type/Mfg / Capacity No. Compartments d l t. PKG. TREATMENT PLT.❑ ` Distance to nearest: Well � Foundatio'�"""""�'nn op��,Method of Disposal . LEACHING LINE C'} No. b Length of lines Total length/size lr FILTER BED ❑ Distance to nearest: Well ' Foundation Property Line T SEEPAGE PITS I I Depth Size " _Number ^ . s ; SUMPS Ll Distance to nearest: WellIf Foundation Property Line DISPOSAI PONDS ❑ ,kr 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. 1 I 4 , 1-1. t Home owneror-licensed-agent's signature certifies the following: "I certify that inglie•performance-of the�work for which.this permit fi.issued,shall not employ any pirson in such manner ss to ioectima.subject to workman's compensation 1awf of California ''Gontrector's-hiring-or sub-contracting signature certifies the following:"I eartity that in the pertormanee of ahs'work for,which this permit is issued, I shall employ persons subject-to workman'i compensa- tion laws of California."' %. I r n The applican uir s. Complets'd4% ing ;ii rover side. Signed X Dpte• / FOR DEPARTME^ USE ONLY -p ,.. ({S Application Accepted byL 'Date �n `� Area a } Pit of Grout Inspection by ata , Final Inspection by Datel € Additional Comments: - - ti/l) •w-� _ -d,,. -_ _ _ .,d �- i Applicant - Return all copies to: SJoaquin County Public Health services S vironmental Health Permit/Services ,�- 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IFEOAMOUNT DUE AMOUNT REMITTED %K S RECEIVED pY DATE PERMIT'NO. • EM 12.24(REV.iiea) R 2 00Ss EK 14•2a y 'A-'10", f a-3bS