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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 I P O BOX 2009, STOC%TON, CA 95201 b PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) + Application in hereby mede,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in cca@11Mce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations Of Ban Joaquin County Public Healt rwicen. �c 1 3. C;;y-��D Owner's Name Lot Size/Acreage Job Address V` Address Phone // q Z � ��i Contractor- Address icense NoJ .r!Phone ' /S TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out °Mcni toting well -service Well ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ l DISTANCE TO NEAREST:_SEPT.IC.TANK, - - ' SEWER-LINES -'-'-"-"'`DISPOSAL FLO. PROP. LINE / FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Sonom ❑ Manteca Die. of Well Excavation Dia. of Wall Casing ;Cl Domestic/Private ❑ Gravel Pack 1 ❑ Tracy Type of Casing_— Speccifications Y Typed Grout" s.. I'1 Public f 1 Other - CI Delta Depth of Grout Seal -�; I I Irnoonon _Approx. Depth I I Eastern Sumace Saul Installed by ;F Repair Work Done ❑ Type of Pump H.P. - - tate Work Done Wali Destruction ❑ Well Diameter Sealing Notarial i Depth � 1 Depth Filler Material s Depth W ~I TYPE OF SEPTIC WORK: INSTALLATION I REPAIR/ADDITION f ! DESTRUCTION 1 I (No ssptic system permitted if public wwsr is }>- 'I available within 200 feet.) O. Installation will Nrw: Residence ' Commercial— Other I Number of living unite ---L Number of bedrooms _ t Chowlsr of ado to a depth of.3 fast'. Water teas depth lX� SEPTIC TANK 't \•l ❑ Type/Mfg, _ _ _. Capacity _ _ _ No. Compenmsnts \l PKG. TREATMENT PLT. ❑ j _. Method OLD >Owl Distance to nearest: Welles�Fgundetion PropenV Lina s LEACHING LINE ❑ No. b Length of lines—' Total length/size FILTER BED j 1-t ❑ DEewnra to merest Well J Foundation __ Property Lira_ _ SEEPAGE PITS , I P-DeSire I - 0 Number i, SUMP i LI• Oleunu to rsiafesC Well . Foundation _ Property Lins ISPOSAL PONDS- b r E haraby comity that 1 hew prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Musa. and rules and regulations of the San Joaquin County ` Home owner or licensed agent's signature unifies the following: "I certify that in the performance of the work for which this permit is issued. I shell not subject employ any person in won manner es to becomebject to workman's compensation laws of California.''Contractor's hiring or subcontracting signsture certifies the following: •'I certify that in the performance of the work for which this permit is issued.I&hail employ persons subject to workman's compsnse- tion lawn of Cohlornla.•' .1 The sppkcan mustcall 1°r uirad in cT a. Complete drawing on reverse side. Signed � --- Title: Date: A�p)plication Accepted by �^ orA re` Dale Area RX or Grout Inepsdion by ate SLt�Ll�- Final Ina uion by �pi��Oats_/J y�a�� _3 (/Additional Canrtsnte: Applicant - Return all copies to: Ban Joaquin County Public t/Sere cerwlces HealthEa� p ✓ S �a�S 445 roamentel Joaquin. P Perini 12009, cee C' 4 I 4 445 N Sao Joaquin, P O Box 2008, Stk., CA 95201 �v'>y' FEE AMOUNT DUE AMOUNT REMITTED CABN RECEIVED BY DATE PERMIT NO. NFO »,33.IaEv r,a, og� a En tale