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'1 APPLICATION FOR PERMIT r SAN4J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 REUIT EXPIRES 1_ YEAR r8QM.,DATE ISSUED (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 Ban Joaquin County Ordinance Ho. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address V'JQ LF City:�6;4ize/Acreage Owner's Nams _1JlJ/ / ✓ Address Phone Contractor,[A—)&14�--A&LL— Address�,a5(Z) Cid. License No. Phone qnse, a TYPE OF WELL/PUMP. - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Gi PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r OTHER ❑ + Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION WELL PITSISUMPS INTENDED USE TYPE OF WELL PRO 8LE k AREA ' U TIO PCI e 0 industrial ❑ Open Bottom ❑ Manteca bia. of WeI Excava +on Dia. of Well Casing U Domestic/Private 0 Gravel Pack L7 Tracy Perm ftywafyi:4"a n rntrerl without Specifications Public 1-1 Other 0 Delta WOE �pq p c( ,yg1}i — n _ff Type of Grout GI Irrigation Approx. Depth n Eastern }, k �;ul . els'lollATO b _� t'� e Repair Work Done U Type of Pump H.4y_ tivirann- ,al [I OeNqfrs ione Well Destruction ❑ Well Diameter Sealing Material & Depth Depth - Piller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l__1 REPAIR/ADDITION UCTION ❑ Wo septic system permitted if public sewer is available within 200 fest.) p Installation will serve: Re idence�_„ Commercial—=Other Number of living units: _ Number of bedrooms d, Character of $oil to a depth of 3 feet: J Water table depth SEPTIC TANK m/rypa/Mfg Capacity No. Compartments 7�16_ PKG. TREATMENT PLT, LlMethod of Di Baal Distance to nearest:. Well Foundation 65 Property Line -5- LEACHING LINE 121,44-o—& Length of lines To pl length/size y FILTER BED E:l Distance to nearest: Weil has Foundation ( Property Line + SEEPAGE PITS I I Depth Site Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 6 _ - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Horne owner or licensed agent's signature certifies the following: "I certify that in the perlormance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature Co if ie$the following; "I certify that in the psrlormance of the work for which this permit is issued, I shall employ person subject to workman's compensa t on law alifornia The applican m ca 1 for al re do s C p to wing o reverse i Sign Title: Date: �ORDEPARTMENT USE ONLY Application Accepted by ad, Data:_y'4— +� _ Area. IS Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ` Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES /11 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMiTTEO CASH RECEIVED BY DATE PEAMl7'NO.