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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 PERNIT EXPIRES 1-YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Ilan Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. . � Pry t e./f i�Job Address`aU �`�"`�v N �OC1 r^1 i Lot size/Acreage al 3 ACIr v-- ,(Owner's Name _��/�!A /`/. � Address' "IFfel 'e Phone ZLI )(Contractor T,Ai A/ K T Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL.REPLACEMENT Cl DESTRUCTION ❑ out of Service Well ❑ UMP 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 L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing tl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'3 Public r:l Other f-1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material & Depth a TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I lNo septic system permitted if public sewer Is available within 200 feet.l 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 Q a !-PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines � Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number '4 SUMPS Ll Distance to nearest: Well Foundation Property Line .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 Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws 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,I shall employ persons subject to workman's compensa- tion laws of California." The appy ant rylasicall for I uir inspections. Complete drawing on reverse ®sidle. C I' x Signed rt Title: ✓v" "`�-� Date: T 0 EPARTMENT USE ONLY Application Accepted by f�/l Gam. ,_ - Date 71-1Area D Pit or Grout Inspection by Date Final Inspection by _ate r 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 952010 I IN AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED 9Y DATE PERMIT'N0. I F tR .tirl�+ 1EH 13-24 H 4.36 r "/� 'J�ta� I17 - 7'