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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 msde to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health 8eryices. Y / [�/J�/l. /U/L/L /�!� Cit Lot Size/Acreage Job Address �,� t, y AMOUNT REMITTED ��-�'��'-" ownsr's Name 7/�/[� .ress //i `- �." Phone ^°c PERMIT NO. Phone Contractor ,a` J dtlress dIo7Q I�II-vim License No. TYPE OF WELL/PUMP: NEW WELL K WELL REPLACEMENT Ll DESTRUCTION ❑ Out of Service Well ❑ l / PUMP INSTALLATION XSYSTEM REPAIR ❑ OTHER ❑ Monitoring W711 W$11 11DISTANCE `1 TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. —^ PROP. LINE � r 2s c/ �� FOUNDATION �-rJ / AGRICULTURE WELL — OTHER WELL PITS/SUMPS � INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private �''Graval Pack ❑ Tracy Type of Casing AO -4-- Specifications C zdtz 1'1 Public�7MOther 11Delta Depth of Grout Seal 4� Type of Grout I I Irrigation aC Pprox. Depth I I Eastern Surf Seal Installed by ROW Work Done U Type of Pump H. P. � / � State Work Dona _ Wall Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I IND septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial T Other Number of living units: _ Number of bedrooms Character of sot to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. 'TREATMENT PLT. ❑ Method o1 Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 6 Length of lines Total length/size FILTER BED ❑ Distance to mortal: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS - _ LI Distance to nearesi: Well - Foundation Property Line DISPOSAL PONDS ❑ ' 14 I hereby certify that 1 haw 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 HMIs owner or licensed agent's signature canities 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 workman's compensation Issue of California." Contractor's hiring or sub -contracting signature cMfip the following: "I certify that in the performance o1 the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applican=8 uirComplete drawing on reverts Ida.. Signed X_ Date: F R DEPARTMENT USE O LY .G� Application Accepted by f . Yt l_'�e� 'M i �> Date S_ LO L� Area �//% �'C��'Z�. �� Pit or L Inspection by `""bate t Final Inspection by�� o 22�'�<fT Dsts 1�j Additional Comments: 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 OPEN Isi4 un. I 14 61 EN 14-3/ INEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED DY DATE PERMIT NO. W e 13y, % i 3 Y- --'- �O i" l Wla " 3=0��