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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 PERMIT EXPIRES 1 YEAR FROM DATE- ISSUED r (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This FL4!' application is made in co4liance with San Joaquin County Ordinance No. 549 and 1862 and.the Rules and Regulations of San Joaquin County Public Health Services. /, / ! E Job Address Imo"' Lot Size/Acreage ,76 ��•��(�C'1-� t Owner's Name 1' �'11� �^' � - L Address F Phone f i Contract 411, LIT-Address r e License No. Phone• TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring 17e11 ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE t FOUNDATION AGRICULTURE WELL bT WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Tr Dia. of Well Caain EI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing SppA,* 11 Public 0 Other 11 Delta Depth of Grout Seal TyAftgt"WED _ _ I I Irrigation,_ —.Approx. Depth I 1 Eastern Surface Soul Installed by ' 1171 La Repair Work:Done ❑ T ? JUN ype of Pump H.P. 5tatq Work Done _ Well Destruction 0 Wall Diameter Sealing Material i Depth I im rm INT Depth Filler Material & Depth nr rtat Ir.1 IFALTH SFFZAl VtC,_S 6 ON TYPE OF SEPTIC WORK: NEW-INSTALLATION I I REPAIRIADOITION i I DESTRUCTION I I (No septic)�S t public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: f Number of Dome r - E I Charscteof soil w a depth of 3 feet: — ' ` i� { `';� Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE No. & Length of lines Total Iength/site Yo X FILTER 13fD ❑ Distance to nearest., Well oundation /0 Property Line SEEPAGE PITS Depth — r Sire t s� Number i , SUMPS LI Distance to nearest: Well &(5" Foundation_-- 3 Property Line -15 _. DISPOSAL PONDS ❑ l S� f E 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, I shall not employ tiny person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fonowing: "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 m tali for u' Inspections. Complete drawing on reverse side. r Signed X Title: -- V Date: U`tL f �. FOR DEPARTMENT USE ONLY ik Application Accepted by a� _ Date_(sj_-f �� Area Z" E Pi r Grout Inspection by ��Z6 Q' pate ��-. Final Inspection by Date F Additional Comments: 6- T• Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 IMFEO AMOUNT DUE AMOUNT REMITTED . CASH RECEIVED BY DATE PERMIT'N0. • EH 1144 fREV.i In EH 14-76 r V //✓ ��/`r � /" ��lY ,� [ l J