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Ia 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 _ISSUID (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 ccuPliance with San Joaquin County Ordinance No. 5 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1 AJob Addre City Lot. Size/Acreage Owner's Name ' Q1fRifaress Ph ' �.` one ContractAddres � X347 1 2-7 No.UM Phon V TYPE OF WELL/PUMP; NE WELL ❑ WELL REPLACEMENT"n DESTRUCI"ION ❑ Out of Service Well ❑ 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 ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom 11 Manteca pia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— Specifications I'I Public C1 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation / _.Approx. pe h LIEastern Surface Seal Installed by Repair Work Done f� Type of Pump vr H.P. _ Stats Work Done Nall Destruction ❑ Wall Diameter Sealing Material L Depth Depth Filler Material & Depth rYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units; Num r of bedrobms Character of soil to a depth of 3 feet. Water table depth ;EPTIC TANK. ❑ Type/Mi g Capacity No. Compartments 1KG. TREATMENT PLT.0 Method of Disposal DistaXv nce to nearest: Well Foundation Property Line } EACHING LIME ❑ No. b Length of linea Total lengthJsixa lLTER BED ❑ Distance to nearest: I undation Property Line iEEPAGE PITS It Depth Size Number r93 LIMPS CI Distance to nearest: Well Foundation Property Line IISPOSAL PONDS ❑ 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 Iles and regulations of the San Joaquin County- lorne owner or li nt's signature certifies the lollowing:""I certify that in the performance of the work for which this permit is issued, I shall not mpioy any n in such nner as to become su to workman's compensation laws of California."Contractor's hiring or sub-contracting signature artifiea the Ibwing: "1 ce fy that in perfor nc 01 the work for which this permit is issued,1 shall employ persona subject to work'msn's compensa- on laws f Calif nis." he ap scant m . t c r all r s a. C plate drawing o ev side/�� igned /�/!/S Ic— Title: Date: FOR DEPARTMENT USE ONLY 2 pplicabon Accepted by, Date Area t or Grout Inspection by _Date Final Inspection by � pate ddhional 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y r CASH DATE PERMIT-NO. i l