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a 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 ISSUED ' (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 is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �"� Job Address -7 2,-7 `1— E �I�: Lo '4' ,- City '""` Lot Size/Acreage Owner's Name BAY y141/E; 6STAO&S Address 6 27 /3-1 G ge� r S TKA4 9S20 2, Phone J&00 IAct u Cts -T $81'7 Contractor Address �t! License No S 3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ ' WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP 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 PR08LEM AREA CONSTRUCTION SPECIFICATIONS w 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing feYCTmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ((�� it Public Cl Other 171 Delta Depth of Grout Seal Type of Grout ^4. I I Irrigation —Approxi Depth`�I IIEEastern Surface Seal installed by Repair Work Done 0 Type of Pump _1 LZ H.P. State Work Done &WOno �-S Well Destruction ❑ Well Diameter Sealing Material A Depth LOL T Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I 1 DESTRUCTION I I (No 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 Sao to a depth of 3.feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ w � Method of Disposal S Distance to nearest: Well Foundation Property Line 1 LEACHING LINE Ll No. & Length of lines Total length/size ; FILTER BED ❑ Distance to nearest: `=Well Foundation Property Line r SEEPAGE PITS 11 Depth `} Size Number SUMPS LI 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 certifies the following: 1 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 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 applicant must call for all required inspections. Co plate drawing on ergo e. Signed V7 Title: C .r14�� Date: OR ARTMENT USE ONLY Application Accepted by Date gs Area Pit or Grout inspection by Date Final Inspection by U• Date 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 11 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO ,q CA5H . EM 13-24 IREV.i,r 5) C d0 kSlaSh-371-0714 EH 14-M r