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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 FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San _ Joaquin County Public Healthy 4ervices�%�7l/ V., 'r/�—`Z.r _ ... IJ_ '% '7i Sr) / -Y /!' / _ n /• —A ///._ u, _is.. G Job Address - - "' ' - - AMOUNT REMITTED _;p/� �' "�� OvNrr's Name Address PERMIT NO. /Phone icense Noir / Phone Contractor Address TYPE TOF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ s=ue` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring 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 ❑ Industrial ❑Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public Cl Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H. P. State Work Done _ Well Destruction ❑ Wall Diameter Sealing Material A Depth Depth Filler Material A Depth TYPE Of SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence j— Commercial _ Other Number of living units: —J— Number of bedrooms --q-_ Character of soa to a depth of 3 last: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 4 No. Compartments PKG. TREATMENT PLT. ❑ Method o/OjW I Distance to nearest: Well J �. b Foundation Property Lim g LEACHING LINE ❑ No. g Length of lines Total length/size FILTER BED _ ❑ Distance to n rest: WNI / fif 0 Foundation _ Property Lim SEEPAGE PITS it Depth LMW Biz, t�W umber �UMP LI Distance to rlearesc Well / �10 Foundation f.1 Property Line. _ L PONDS ❑ r v 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 =4tions of the San Joaquin County Horne owner or licensed agent's signature prtifies the following: "I certify that in the performance of the work for which this permit is issued, I Mall not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub -contracting signature aNfies 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 compenss tion laws of California." The applican must call for wind inspect ns. Complete drawing on reveres side. Signal 7L �� Title: C, Date: 11 ' ti lNiil6EJ1 pate 1 I Afp�pliatbn Accepted by A Or, L Q Area /1n 01 Grout Inspection by ate 5"-ld��%' 3 ,Fi-nail In�tctian by rL'�� /��'/i��.(,/ Date ,r��— -3 Addltiqul Commsn4: 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 - IM 1124 lasv. 1, x s. EN 1a-2• FEE NfO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. Ll Af oda 111f -a6 l(�2 T s=ue` 1�3 o$10