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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 -YEAR (Complete is 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 compliance with San Joaquin Cc ty Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public�ea�t�9ervic� �� D Job Address 55 �5 .rrs7J� e / t/ J � f (�(� City t Size/Acreage `}' Owner's Name �„ G�.H Y� Address Phone 13 Contractor AddressLicense No.�e i —. 37 Phone _ fY] TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION 0 Out of Service Heli ❑ PUMP INSTALLATION� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 tkIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications_... R Public !-1 Other ❑ Delta Depth of Grout Seal Type of Grout Gi Irrigation — Approx. DepthL ❑ Eastern Sufface Seal Installed by Repair Work Done 0 Type of Pump t2 tb . H.P. 6ohp State Work Done_ Well Destruction ❑ Well Diameter IIy ` Sealing Material 4 Depth Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION 0 DESTRUCTION M iNo septic system permitted if public sower is Installation will serve: Residence_ Commercial— Other available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mf 17 Capacity No, Compartments PKG, TREATMENT PLT. ❑ { Method of Disposal Distance to nearest:' ;Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Y Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Siie Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I 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 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 workman's compensation laws of Catifo(nia." Contractor's hiring or sub-contracting signature certifies the following; 1 certify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compansa- 111 tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. 4 Signed —�--��_ Title: Date: Zi— 2 ELz�__ FOR DEPARTMENT USE ONLY —/ Application Accepted by Date / ;7-f ,gi) Area �/�J Pit or Grout inspection by Date ~ -�._._., Fina! Inspection by�- � Date 0 O Additional Comments: Applicant — Return all Copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O SOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO ma�-yy,, CASH PATJyJE�Q�(�] PERMIT N0, • t;H 11-24iREY.I/N51 � 0 tyV /! "` I'y FO �� :3)-�,9 EN:426 VV