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w APPLICATION FOR PERMIT 2 � SAN JUAQUIN COUNTY PUBLIC HEALTH SjsRVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT MIRES ] YEAR FROM DATE_ ISSUED (Complete in Triplicate) Application is hereby made.to 8an.Joaquin County for a permit to construct and/or install the work herein described. This application is.msde in casIpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 0Q a u City hdG Lot Size/Aereag�l - 0- a s Name aP, Address 5Pfione 1 Q .5 3 I' 1 .�• � �I� CLQ _.License No �-3 Phone Contractor Address TYPE OF WELL/PUMP: NEW WELL JK WELL REPLACEMENT C] LDESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELLJA� OTHER WELLII-!— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT10(15- k 0 Industrial "Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing ' Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing.SIVP� f -- Specificationse}� I'1 Public n optir I7 Delta Depth of Grout Seal yps.af rout I I Irrigation �.Approx. Depth _- rI I Eastern urface Seal Installed by � �L pU �int ?T Repair Work Done U Type of Pump H.P. '. a S1at4Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material ii Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION-I I DESTRUCTION1 I INo septic.system permitted if public se"r..is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of twit to a depth of 3 fest: Water table depth I SEPTIC TANK 0 Type/Mfg Capacity-- No. Compartments f ' PKG. TREATMENT PLT.,[] Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE 0 No. b Length of lines Total length/size 1' FILTER BED ❑ Distance to nearest: well Pr ` _ aperty Line ; i SEEPAGE PITS 11 Depth Size Number, SUMPSLL1 Distance to nearest: Well Foundation Property Lino ` i DISPOSAL PONDS ❑ 0. I hereby certify that I he"prepared this application and that the work will ba':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, 1 shall not y employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature.' culifies the following:"I certify that in the peAomence of the work,for-which this:permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant MUSUC4A for MI requ'ad Inspections. Complete drawing on reverse side. Sig Title: �� /==4 Date: FOR DEPARTMENT USE ONLY ' Application Accepted byDate Areaj Ph or Grout f spact'ton by • Date Final Inspection by a}ta r Additional Comments: Iry rr Applicant - Return all copies ta^ Joaquin County Public Health Services �c� £nviroomental Health Permit/Services JIf(f �1 445 N San Joaquin, P O Box 2009, Stkn, CA 95201. r IFEE NFO AMOUNT DUE AMOUNT REMITTED CK BY 0 TE PERMIT'NO. J ♦ EH 14.28