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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 PERMIT EXPIRES 1 YEAR FROM DATE -I-SSUED (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 1a made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and RegulAtions of San Joaquin County Public Health Service, • -y/l� Job address � � ' City Lot Size/Acreage Owner's Name t Address L- fry�7 1�_-) Phone L Contractor O�Cf` !C1 �T� �Rddre�s License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATI N ❑ SYSTEM REPAIR 9KI, OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 6z422 DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial OO�pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private 2Gravel Pack ❑ Tracy Type of Casing Specifications i'I Public Ci Other n Delta Depth of Grout Seal Type of Grout Ii.HrGation _.Approx. Depth �f',I�,I Eastern Surface Semi Installed by Repair Work Done U Type of Pump H.P.' a State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Deptli 1^� Depth Piller Naterial i Depth f�`._ S-- �/ / TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soll to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Pr 5 operty Line 1� LEACHING LINE ❑ No. A Length of linea Total length/size FILTER BED 1.7 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 shalt not employ any person in such manner as to become subject to workman's compensation taws of California." Contractors hiring or subcontracting signature certifies the following: "I certify 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 s atr ins Cti s. mpiete drawing on reverse side. SignedTitle: Date: 9 4 X? FO ONLY Ci Application Accepted by Date ` a —OL ZArea Pit or Grout Inspection by Date Final Inspection 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 FEE INFO AMOUNT DUE AMOUNT REMITTED L�� RECEIVED BY GATE PERMIT'NO. . EH 1S•I4 1111V.t!N 61 /�.� EH 14•25 1