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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. RAZELTON AVE., PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Applieatim is hereby emde.to Sm Joaquin County for a permit to construct and/or Install the work herein described. This application is made in compliamce with Han Joaquin County ordinance Ho. 569 and 11,862 and the Rules and Regulation, of San Joaquin County Public Health Services. y //9 /o% -< 0.2-'B A -y rpt Size/Acrease JOm AOorOSa _ 32 '//G� Owner's Nas s Ph. C�1, � t .7�t�1 ,7 license No. Ph Contracts � J Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Yell ❑ DISTANCE TO NEAREST: SEPTIC 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 Bottom ❑ Manteca Dia. of Well Excavation Da. of Wen Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"I Public ❑ Other (l Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAfR1ADO(WN myDESTRUCTION I I (No septic system permitted if public sewer is available within 200 feel.) Installation will serve: Residence v Commercial— Other Number of kvmg units: Numberbedrooms 3._ / Character of coil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLL ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C4 -'-No. R Length of lines Total length/size S FILTER BED _ ❑ Distance to nearest: FasdaIion� Properfli Line G7QQ r SEEPAGE PITS __��__!�Wem KY Depth ,n,�Siii6 I V- Number SUMPS �,r. LI Distance to nearet: Wall O Emendation Aolbl Property "Line010 If DISPOSAL PONDS ❑ " I hereby certify that 1 have prepared this application and that the work'aW be done in accordance with San Joaquin county ordinances. state laws. and rules and regulations of the San Joaquin Canty Home owner o licensed aganty eignature_cerefies 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 workmen's compensation lawIr, of Cakfo nia." Contractor's hiring or subcontracting signature certifies the fomowing: -I ceruty that in the performance of the work for which this permit is i"yeld. _I"shNl employ persons subject to workmans compensa- tion laws of California. - The appfic- must Cam foX.NVw inspections. Complete drawing on fJ ro_e side. Signed f%aCf/n Title: �!fi�l/iZL-. Data: FOR DEPARTMENT USE ONLY Application Accepted by /� Date&- 7-7/GI �/��,,, ��lllArre��a �/� �Piyor Grout Inspection by _ Date �L/Fml Inspection by � � ets" / v I Addhional Comments: Applicant - Return all copies to: San Joaquin Canty Public Health - Services, Huvlrcmestea Health Permit/Services 1601 H. Hszeltam Ave., P 0 Hoz 2009, Stockton, CA 95201 INfO AMOUNT DUE AMOUNT flEM1T7ED CK II RECEIVED BY DATE PERMIT NO.