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APPLICATION FOR PERMIT ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t ENVIRONMENTAL HEALTH DIVISION 1 �; P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-344 34-"�' / r. PERMIT EXPIRES 1 YEAR VROM DATE ISSUED (Complete in 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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address l nl v l e--- City 5 7-x-r'- — Lot Size/Acreage V Owner's Na e — ��Yf� 1- s Address D�. �' - 1 T_Z �" . Phone —✓ f 5 7 \ Cih �c�`�—S � L �9' 3 Phone Contractor 0 �� Address D 7 License No TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 7� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-_ Specifications , M Public 1:1 Other ❑ Delta Depth of Grout Seal - Type of Grout MI IrnOation Approx. Depth ❑ Eastern Surface Seal Installed by_ (/ Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Wolf Diameter Sealing Material i Depth Depth Filler Material i Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADOITION DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial __& Other Number of living units: Number of bedrooms / Character of soil to a depth of 3 feet: a Water table depth 1 r SEPTIC TANK ❑ Type/Mfg t`L Capacity �16a No. Compartments Z PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation _ Property Line p 1 LEACHING LINE ( No. & Length of lines a Total length/size FILTER BED C) Distance to nearest: Well _ Foundation Property Line rr SEEPAGE PITS Sip Depth cS Size Number SUMPS LI Distance to nearest: Well Zkteh Foundation ��_._ 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 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 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." Th=tt for all r ��inspe. ons. Complete drawing on reverse sioe. ? Sig _ Title: 61J_A=t" Date: OR DEPARTMENT USE ONLY Application Accepted by mate __�0=4AreaIf _ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: LL .' - ��...� - e..,�, A--h ° _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 13-24 IREV.I/n 57 C^•,(�. (_ (� EH A-26 __ c_.1�� 2 3 �t `�1—�