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APPLICATION FOR PERMI" SAN JOAQUIN COUNTY PUBLIC HEALTII SFRVICE9 �, ENVIRONMENTAL HEALTH DIVIS 02+'�� F 445 N SAN JOAQUIN, PHONE (209) Zl,� P O BOX 2009, STocgTON, CA c PERMIT EXPIRES 1 YEAR FROM DA Er /✓ (Complete in Triplicat )I `1, Application is hereby made to San Joaquin County for a permit to construct and `/ he ein described. Th s application is made in coo>pllance with San Joaquin County Ordinance No. 549 and 1862 and ions of San J0a4u1n County Public Health Services. J Job Address ;k - Y 6 A (7 Wf��w�`, � City SrOQy�O,/� Lot Size/Acreage Owner's Name )' &O/{ llycl Vi Q yy,4 Address S.4Mcs- Phone Contractor J'1�71141 Address 600,7 LvM ��' /f90�Fj/D License No. 9� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 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 Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public Cl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. Ste to Work Done _ C Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material IL Depth- TYPE OF SEPTIC VYORK: NEW INSTALLATION I,t REPAIR/ADDITION JCI DESTRUCTION I I (No septic system permitted if public sewer is 3` available within 200 feet.) Installation will serve: Residence _L_ Commercial _ Other Number of Irving units: Number of bedrooms Character of sog to a depth of 3 feet: y Water table depth too ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl r ,.Method of Disposal Distance to nearest: Well Foundation Property Line (, r\ LEACHING LINE No. 6 Length of lines y0 Total length/size r\� FILTER BED ❑ Distance to nearest: Well Foundation Propelrty Line SEEPAGE PITS J0 Depth R S ^ Size.. :�6 �� Number SUMPS LI Distance to nearest: Well d0 'Foundation 0_0 Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will..be done in accordance with San Joaquin county ordinances, state taws, 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 sub-contracting signature certifies the folbwinQQ "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 CaliforrrTa." The applicant m st call for all required inspections. Complete drawing on reverse side. Signed X �� Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Daterea Z 1 tit rout Inspection by U Date 1', Final Inspection by Date Ad r ' \1 Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMIT-TED RECEIVED BY DATE PERMIT NO. INFO CASH _ EH13-24111EV.1/r,SI �i loll ' EH 14-26