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i 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 MIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application to hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This � application 1a made in coliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �`�� •CtZ�Ch\ C.�`e��1/,.Ir._• City Lot Size/Acreage Owner's Name ��- `+WgM11ito Address ::s Phone Contractor Address \ License No:yCj �� Phone TYPi OF WILL/PUMP; NEW WELL O WELL REPLACEMENT !'1 DESTRUCTION Cl Out of Service Well Gl PUMP INSTALLATION O SYSTEM REPAIR OTHER O 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 n Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing (� Domestic/Private n Gravel Pack ❑ Tracy Type of Casing_ Specifications 4\\ I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. De th 11 Eastern Surface Seal Installed by (� Repair Work Done U Type of Pump H.P. - \ . Staii Work Donee !►��gQ► ��Wt v\ Well Destruction O Well Diameter Sealing NaterilIl A Depth Depth Tiller Material A Depth 1 �y TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I INo septic system Oermitted if public sewer is available within 200 feet.) Installation will some: Residence_ Commercial_ Other _- f t 1 Number of living units: Number of bedrooms Character of will to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: err 1 undetion Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED n Distance to neo►eat: Wall Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 sub-contracting signature certifies the following: "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 California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed Xm\a1+ ��o..7�i� Title: ��J� - aZ��. Date: � FOR DEPARTMENT USE ONLY I Application Accepted by � Data � Ar 0� ` Ph or Grout Inspection by Date Final Inspection by Datr� 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 CIf INFO FEEAMOUNT DUE /AMOUNT REMITTED - /K RECEIVED SV GATE PER//MI��T'N0. .H 14.11 IN NO. t{a Pk / 1 f , )O �H 1�•M 1 /