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APPLICATION FOR PERMIT V 0 SAN OAQUIN COUNTY PUBLIC HEALTH rERVICES ENVIRONMENTAL HEALTH DIVISION L 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 mede.to Sia Joaquin County for a Permit to construct and/or install the work herein described. This application is made In compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,,/, (/^�]/{_.4 XJob Address 1� MGCn City A�4 I Wt Size/Acreages QC-f X\Owner's Nam//�JJfe(�� /�i Address 1,� ��n D Phos �6 —" v" /<Contractor yy= Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A ICULT WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS ❑ industrial 110 Open Bo ❑ eca Dib-of Well Excavation Dia. of Well Casing me ❑ Dostic/Private L, Gravel ack Tracy Type of Casing_ Specifications Pt Public I- Ot fl Delta Depth of Grout Seal Type of Grout I I Irrigation "'ApproX. Depth 11 Eastern Surface Seal Installed by V Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material a Depth _ Depth Piller Material E Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is vailable within 200 lei Installation will some: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of sole to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. g Length of lines Total length/size FILTER BED ❑ Distance to merest: Wall Foundation Property Lina Gy SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to merest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that I has prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and ragulatiore of the San Joaquin County Harr owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in such seiner as to becoar subject to workmen's compensation Isws of California."Contractor's hiring or sub-contracting signature certifies the following: "1 certify,that in the peAormence of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." — The applicahmust ""1 ale ms cans. Complete drawing onreversee side. p Q q _ Signed X- Title:Title: &&!1dZM Date: �yI/'' ,yf� FOR DEPARTMENT USE ONLY Application Accepted by ,� /C/y Date 7 9'� Area Ph or Grout Inspection by Date Final Inspection by--?� � Date 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED my DATE PERMIT'NO. . EH 13-24 IREV.vx 5 f 17 51 0 ' O r^ 21 EH 14