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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PE_RMTT EXPIRES 1 YEAR PROM DATE ISSUED (Complete in Triplicate) Application is hereby made,tp San Joaquin County for a permit to construct and/or install the work herein described. This application 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Reg4lAtions of San Joaquin County Public Health Services. /� J A � Job Address 'U City �`�"/ Size/Acreage Owner's N - Addresf��ZZV �o�3rlGL Phone �� = 011 Y Conti ct 6 License No.040�1� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM NT (1 DESTRUCTIO t of Service Well Cl PUMP INSTALLATION_❑ SYSTEM REP IR ❑ OTHE ❑ Monitoring Well f� DISTANCE TO NEAREST: SEPTIC TANK �(j— SEWER LINES �[1— DISPOSAL FLO, PROP. LINE t2 + FOUNDATION AGRICULTURE WELL "� OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications * Public I"l Other ❑ Delta Depth of Grout Seal Type of Grout U Irnpauon -_-_ Approx. Depth ❑ Eastern Surlace Soul Installed by Repair Work Done U Type of Pump H.P. State-Work Done —_ / Well Destruction /K Well Diameter sling Material & Depth �JJy!G�`^ Depth f ler Material i Depth �� Y IN/rd! TYPE OF SEPTIC WORK: NEW INST TIONi7 IR/ADDITION Cl DESTRUCTION CI (No septic system permitted if prlblic sower is available within 200 leet.l Installation will serve: Residence —. Commercial _ Other n Number of living units: Number of bedrooms CIP Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments S PKG. TREATMENT PLT. C1 Method of Disposal Distance to nearest: Well Foundation Property Line ly LEACHING LINE LI No. 6 Length of lines _ Total length/size \� FILTER BED CI Distance to nearest: Well Foundation Propeny Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 sub-contracting signature canifies 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 Californlo." The applicant m all fo all required inspections. Complete drawing on favor s e. ,y Signed Title: _�� Date: FOR DEPARTMENT USE ONLY QQ Application Accepted by Dattaa�AL-_'Ao 91D Area Pit or Grout Inspection by Date Final Inspection by��G—�-=J--' Dace 11 L `} "d Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 IEEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13-24 INEV.1/x$1 IN a-M C .OR-> C f