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APPLICATION FOR PERMIT (—N SAN JUAQUIN 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin CountyPublicHealth Services.J Job Address �TEP , City Lot Sizerz e e vuk Owner's Name !e55 Phone Contractor Address License No. Z Phone 64 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Xonitoring Well C] 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 LI Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Die:of We'll Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'l Public n Other 171 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Typo of Pump H.P. State Work Done Weft Destruction 0 Well Diameter Sealing'E lfaterial i Depth v Depth 1!ilJer a4terial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDI�TION I I DESTRUCTION I I (No septic system permitted it public sewer is available-within 2W feet.) Installation will serve: Residence_L Commercial_ Other I Number of living units: __L_ Number of b2oroormns; Character of soil to a depth of 3 fat: i i Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of flitsal # Distance to nearest: Wei Foundation 3 Property Line, ICD LEACHING LINE Cl No, i Length of lines 49,2 Total length/size FILTER BED ❑ Distanea to nearest: t Well 3.40,2 _ Foundation d Property Line SEEPAGE PITS I I Depth C Size Numberr Ill Distance to merest: Well Foundation Property Lina B DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Horne owner or licensed agent'n signature certifies 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: 1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion larva of California." The applicant must 11 for all ed spsslctionto drawing on reverse side. ! " /+ Signed s. m Title: 4 ::: . Data: / / !!'J FOR DEPARTMENT USE ONLY Application Accepted by Date 3�11'1-3 Area __:0 Z� Z Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services _n Environmental Health Permit/Services 445 H San Joaquin, P 0 Box 2005, Stkn, CA 85201 ![�� INFO EEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE �}PERMIT'NO. . E„13.24 IItEV.t/asl 5 IN L f EN 11•Za l J 1 /✓VV