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APPLICATION FOR PERI[I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION k 445 N SAN JOAQUIN, PHONE {209}468-3420 P O BOX 2009, STOCKTON, CA 95201 PERH T EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application ia`hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in cestpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address p " "� " Caoo City&-0/0 Lot Size/Acreage Owner's Name AddressVo _ Phone N 17 Contractor Address A License No. '3 Phone `' ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing 17.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1-1 Other fl Delta_ Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Said Installed by Repair Work Done L7 Type of Pump H.P. ` State Work Done ,Well Destruction ❑ Well Diameter Sealing Material A Depth !� Depth biller`Material i Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I I -REPAIR/ADDITION j0716ESTRUCTION I I (No septic system permitted if public sower is available within 200 feet.! Installation will serve: Residence Commercial Other Number of living units: #— Number of bedrooms �Q Character of still to a depth of 3 feat: _., Water table depth SEPTIC TANK. ❑ T ype/Mig Ca acit P Y No. Compartments PKG. TREATMENT PLT. ❑ _ _ Method of Disposal Distance to nearest, Well Foundation Property Line I ' LEACHING LINE 13"o. & Length of linea _� Total length/size f FILTER BED ❑ Distance to nearest: Well Z:S22L-1�_ Foundation Property Lin __63 / 02 SEEPAGE PITS I 1 Depth __- Size* G Number SUMPS LI Distance to nearest: Well 1.fm t FoundaiioProperty Line-1a DISPOSAL PONDS ❑ 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 Home owner or licensed agent's signature certifies tha'following: :'Fcertify 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 Iaws'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,1 shall employ persons subject to workman's compensa- tion laws of California." The appllc t call for all repiref inspections. Complete,drawing on reverse side. J Signed Title: Date: 'Z7 FO NT'USE ONLY Cj �,' Applicatbn Accepted by _� ��f Date f Area_ O, t�or Grout inspection by ``�-i3at Final Inspection by Date- (f 4� �1J � I Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO l //AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DA TE PERMIT'NO. . EH 13 IREV. it 51 �C / / 1 10,01 '� G, EH 14.10 ! .