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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXP I RES I XM FROM DATE ISSUED (Complete in Triplicate) Applictition 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health 8 ices.GL Job Address S V�_k l City 49�l Lot Size/Acreage IQ� Owner's Namer'T`�" � Address Y U f�T/)-7 _ Phone Contractor Address ��N License NoC_?(0457-?/ Phone � TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i 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 Dia. of Well Casing fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications I'1 Public 1-1 Other 171 Delta Depth of Grout Seat Type of Grout I I Irritation —.Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material A Depth [ n TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION DESTRUCTION l I iNo septic system permitted if public sower is V available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: ___J_ Number of badmorns _ � I Character of soil to a depth of 3 feet: — o 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 L�No. 6 Length of linea Total length/size d FILTER SED ❑ Distance to nearest. Well 1 Foundation if Properly Line ?=c _ SEEPAGE PITS P-�-Deptlh Size _ Nember r SUMPS LI Distance to nearest:. Well �a Foundation Pro t party Line DISPOSAL PONDS ❑ I heraby 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 Sen Joaquin County #coma 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 10.workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "1 certify that;in the performance of the work for which this permit is issued, I*hall employ persons subject to workman's compensa- tion laws of California." The applica st ll for all requiradA s C ns. Complete drawing on reverse side. Signed Title: IQ Date: F DEPARTMENT USE ONLY n Application Accepted by _ _ te e.-a. _ !�p Date ��,.�, ,,....._ Area �� _TN` i or Grout Impaction by DatesFinal Inspection by � Data Additional Comments: A Applicant - Return all copies to:M1 San Joaquin County Public Health S-ervices Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201guv v1Q5 INFO FEE AMOUNT DUE A`MOVNT REMITTED SM ECEIYED BY ATE PERMIT NO. • EH 13.24(REV.i/x 611 �� w l `© � / l ^► EH 14.26 ( v 11 ` p