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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 PERMIT EXPIRES 1 YEAR FROM 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 in 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 1, JZ i :!:-, 6 &JAnAkZX City Lot Size/Acreage / IL � � ,�� `7a 7 ' Owner's Name d tit► �fZL -�C Address �2a ( �J Gf V O ►1'IP) one Contractor L& I La V t._.0Rt �![1` ddress �r� -ff�0NL q� (5A11TLicense No. 9�� Phone-&9--1,1 TYPE OF WELL/PUMP: NEW WELL 0 WELL-REPLACEMENT ❑ _DESTRUCTION'XOQt of`Service Well Cl 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 CI Industrial �Q-Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications i"1 Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approxi Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. Stat o Done l Well Destruction ❑ Well D JamIter Sealing Material & Depth Depth= 1 Filler Material & Dept J�j . - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I I (No seplic system permitted if public sewer is = available within 200 feet.! Installation will serve: Residence Commercial,_- Other Number of living units: Number of bedrooms l Character of soll to a depth of 3 festa Water table depth I SEPTIC TANK. ❑ Type/Mfg _ Capacity No, Compartments `v PKG. TREATMENT PLT,0 f k.. . Method of Disposal i Distance to nearest: Well_ - Foundation Property Line i LEACHINGL"INE—'"—-LI—No:&'Length of'lines Total length/size FILTER BED 0 Distance to nearest: -Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f t 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 3 rules-and regulations of the Sen 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 shell not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,!shall employ persons subject to workman's compensa- tion laws of California." The applicant must call f allr fired 'nspactions. Gomplate drawing on reverse side. Sip Title:S e,:, /Z CS Data E I FOR DEPARTMENT USE ONLY t Application Accepted by \ Date Z L�t Area - _ p • der, Pk or Grout Inspection by Date Fig nal lnspection_bY Data- �w Additional Comments: Applicant - Return all c9pies.to: San Joaquin Countq Public Health Services � ' .. bwo� Y �,J� ctt�2�cn,..t� ItJI�/ j� Environmental Health Permit/services G�L� FEE f y` 445 N San Joaqu O Box 2oas, Btkn, CA 9520 �•� �' f INFO AMOUNT DUE AMOUNT RE I EDI(y ASH If IREC IVEp Y E PERMIT N0. tu• ^ a EN 13lips) �© X Wti►�tJ EM t4-M (J