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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 O 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �� f 53 7 City tf Lot Size/Acreage Owner's Name � /Z vu ress 853 101101& /5ZD Phone Contractor ddress tL � . License NoAW/46 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT R DESTRUCTION Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L-) 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 Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public F1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by TTS Repair Work Done 0 Type of Pump H.P. State W rk D Well Destruction may; Well Diameter Sealing Material 4 Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permit) d if�blic�0 available within 200 feet. Installation will serve: Residence _ Commercial_ Other Number of living units: Number of bedrooms j Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 00 rules and regulations of the San Joaquin County (('�v��U��IIll111l11 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies 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 compensa- tion laws of California." The applicant c o NI req ions. Complete drawing on rover P side. Signed X ' ��Q�/� j�� :!� 1�`-Title: - Date: �- l FOR DEPARTMENT USE ONLY �3 / Application Accepted by r Date Area Pit or Grout Inspection by Date ,�1 Fin Inape�c/U/on by 5. , l Date Additional Comments: y� ^Y ` �`� 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 FEE INFO AMOUNTT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. EH/7-24(REV.I/AS) � 6© / /r �7 �G EH 14.2a f/ (�'� `7