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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 Sari Joaquin County for a permit to construct and/or install the work herein described. This application to made in costpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ( � Q t i»/b�&,YA P -.0 gC,iitty /.//y�i6.A�2fj/L t Siyz�e/AAcrreage / A 11'Owner's Name /i� �s1�Address ��SI�/If Cr/� /FF/"�_Phone �� 1 IA NZI Contractor f 7 .ys ddress PZI,174, /LC License No. Phone 'TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 171 DESTRUCTION El t- of Service Well ❑ f PUMP INSTALLATION J SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK ZCC / SEWER LINES — DISPOSAL FLD—. PROP, LINE S� FOUNDATION _-Z.5 AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 1!ZV- p\� INTENDED USE TYPE OF WELL PR09LEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f Dia. of Wall Casing (� XDomestic/Prlvsta XGrovel Pack ❑ Tracy Type of Casing__ Specifications �� lea, I'I Public if 1-1 Other n Delta Depth of Grout Seal 0 Type of Grout MEIV494AA I I Irrigation YS _-1 OApMox. Depth I I Eestem Surf ce Seal Installed by / ili1� LIL I S �/ZIL,1 JA14 Repair Work Done U type of Pump S!0"lam H.P. !__4Z_Z State Work Done _ Well Doetruction ❑ WON Diamster Sealing 011aterial i Dept Depth Filler Material rt Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation wife serve: Residence_ Commercial_ Other Number of (ivinp unite: Number of bodroomt � Cherecrer of sol to a depth of 3 fast: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ( PKG. TgEATMENt RLt. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER ®ED ❑ Distends to neireat: Well Foundation Property Line SEEPAGE PITS It Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lino DISPOSAL PONDS .. ❑ 1 hereby comity that 1 have prepared fWs application and that the work will be done In accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Sin Joaquin Cdlu,ty Home owner of licensed agent's signature cartif!"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." Controctor's hiring or sub-contracting signature comifiM the following: "I certify that in the performance oUhs work for which this permit Is issued, I shall employ persona subject to work man'alcompones tion laws of California." The applicamt �mwtbions. Complete drawing on rover" side..Signed X 10, 0 Title: �i��iC-f` +� Dote: 3/ DEPARTMENT USE ONLY / Application Accepted by M '"N Data Area v Pit rou Inspoctlon by Date L Final Inspection by Date II-- 11 Additional Comments: 'iD 6 Applicant - Return all copies to: San Joaquin County public Health Services Iff*VX 7'+ kr Of CdSr� lSoviroamental Health Permit/Services /lecdq Gad/Kc� 445 N San Joaquin, P O Box 2009; Stkn; OA 95201 - IFFO AMOUNT DUE AMOUNfi MITTED CK I CASH EIVED BY ATE PERMI7 NO. .-IN 17 M IIItV $,a%) A t / - Err q.1f /v' l t V cc) 17� I