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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 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FR M DATE ISSUBD (Complete in Triplicate) i A is re-by made,to San Joaquin County for a permit to construct and/or install the work herein described. This a' in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San J n c Health Services. ob Address City Lot Size/Acreage XOwner's Namal"1/f �!d(`G"rte-�'/� Address �' � ?Phone ^ fT- Conlracttu Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cn DESTRUCTION ❑ Out of Service well. 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ldonitoring 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 C7 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i1 Public 1-1 Other fn Delta Depth of Grout Seal Type of Grout J I I Irrigation .—.Approx. Depth I I Eastern Surface Soul Installed by Cl. Repair Work Done 0 Type of Pump H.P. State Work Done Q 1 Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Tiller Material 4 Depth YPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.} Installation will serve: Residence 4 Commercial_ Other Number of living units: , Number of rooms --- /Zp Character of soli to a depth of 3 feet: 1 Water table depth SEPTIC TANK. 21- Type/Mfg +�"'<Y Capacity No. Compartments L PKG. TREATMENT PLT. D /�� f I Method of DisRosaI Distance to nearest: Well HCl Foundation Property Line _ T` gyp, LEACHING LINE No. 6 Length of lines O Total length/size Zv FILTER BED ❑ Distance to nearest: Well 00 Foundation D Property Line �o SEEPAGE PITSltI/ pth yZ_S ---__-_ Size _+ Number SUMPS Distance to nearest: Well ound",,62 to Property Line _ S DISPOSAL PONDS ❑ I hereby certily 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 oanifies the following: "l 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 Callfornla." The applicant t tail for ail red ins Ctions. Complete drawing on rev side. igned Title: - --� Date: 2— z 21,9Z— FOR DEPAR7MEfV7 USE ONLY p� 1 Ap ;I by Date 1Z Area ZI Pit r Grout Inspection by Date�� Final Inspection by Date dditional Comment:: 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 FEE AMOUNT DUEMOUNT REMITTED SH RECEIVED BY DAT PERMIT'NO. INFO EM 13.24(REV.i r R ss s / 'D EM 14.18 tV L vV�+