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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 eospllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County /Public Health Services. Job Address `/ / ��C ✓« City o Lot Size/Acreage Owneis Name /��1�/ Address '1y�.�'� Phone Xt, Contractor 6y-(—P- Address _,,Z� License No. ,,7052AI Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ 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 _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing r Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i'I Public 11 Other rl Delta Depth of Grout Seal Type of Grout I I Inlga(ion _Approx. Depth I I Eastern Surlace Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material a Depth (� TYPE OF SEPTIC WORK: NEW INSTALLATION 1r REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is \\\• available thin 200 feet.) Installation will serve: Residence _ Commercial e/ Other�,LCee,eati Number of living units: _ Number of bedrooms Character of li to a depth of 3 feet: Water table depth SEPTIC TANK E}--Type/Mfg - `f Capacity i6OD No. Compartments PKG. TREATMENT PLT. ❑ Method of Di -�7�^ Disposal Distance to nearest: Well Zi r Foundation Property Line rP r LEACHING LINE L41—No. 6 Length of lines �/ 7 r�o i T�otal length/size i/ FILTER BED ❑ Distance to nearest, We //O / Foundation ^�,�+�" Property Line !D / N SEEPAGE PITS 14- Depth �2Sr Size //p��,�sY� / Number \ SUMPS LI Distance to nearest: Well lf� Foundation 106 i)o Properly Line / DISPOSAL PONDS ❑ 1 hereby sonify 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 regulations of the San Joaquin County 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 workmen's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compon is tion laws of California." The applicant must callfor MI requipail in coons. Complete drawing on rev ers e side. Signed `!/ ! n Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by lS1Y�,Y/\ � ' Data 2 Z Area Pit or Grout Inspection by Date Final Inspection by Data /j 9 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 I FEE AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DAT PERMIT NO. J . IN 3-24 iNEV.1 51 FH I4211