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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 0 BOX 2009, STOCKTON, CA 95201 PERMLTEXPIRES I XEM FROM DATE S (Complete in Triplicate) Application in 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 k)e)Ll d Cj JGity Lot Size/Acreage i Owner's Name �G[ w d2 a Address Phone Contractor, I11 J=ti i �I(ri_ ddress f ill 51- i&X +�fTl CJJr�i-)cense No Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION Q Out of Service Keil 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Dg.D 14"jitoring Well ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr Fel Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation lez Dia. of Well Casing C fl Domestic/Private Cl Gravel Pack C7 Tracy Type of Casing_ Pilef� Specifications ('1 Public 171 Other 11 Delta Depth of Grout Seat Type of Grout e I ! Irrigation 7 F Approx. Depth I I Eastern Surface Seal Installed by Mt&W ,11C'L Repair Work Done LJ Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth FillerMateriali Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic-system permitted it public sewer is available within 200 lest.) Installation will some: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soN to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ —Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. S Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS. .Q 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 licensed agent's signature certifies 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 subcontracting signature certifies the following: "I unify 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 ust call for all required inspections. Complete drawing on reverse side. 7 7 r�� f Signed Title: DaI "OLa 1 O EPARTMENT USE ONLY Application Accepted by DateArea4001, Pit or ouT Inspection by ate Final InapecNo - 1 - Additional Comments; �mllel .01 1rte - r--� Applicant - Return all copies to: San Joaquin County Public Health Services r � Environmental Health Permit/Services 445 N Sao Joaquin, P 0 Box 2009, Stkn, CA 95201FEE 1 INFO �jAMOUNT DUE AMOUNT REMITTED �Cj�AS�H� RECEIVED By PERMIT'NO. a EM 13,24 IREV. EM 14-711 V