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kN PLICATION FOR PERMIT S PUBLIC HEALTH VICES AL HEALTH DIVISION 5 N SANOA N, PHONE (209)468-3420 S ep Ol B9W09, STOCKTON, CA 95201 PERMIT -FMIRES I YEAR FRPM DATE JgJSURD ENVIRONMEQ�I�T$� in Triplicate) PERMITISERVI ES 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 vith San Joaquin County Ordinance No. 549 and 18k and the Rules and Regulations of San Joaquin County Public Health Services. �j7 � kf 041 Job Address f City I Lot Size/Acreage Owner's Name [1lL a-P_q1nc4nk;r1 Address/ 6 5 1 l-,%nco/!°I ✓/7�C _ _ __ Phone Contractor r Addresso �t�� 31f? License No. Phone '� TYPE OF WELL/PUMP: N WELL 13 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Nell ❑ PUMP INSTALLATION I-] SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 42? DISPOSAL FLD.XZ4_ PROP. LINED FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 2 tr RYDomasti Pr vote ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'1 Public 1-1 Other A Delta Depth of Grout Seal Type of Grout I I Irrigafion _.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system public sewer is available rRi30 feet.) Inst tion will serve: Residence— Commercial— Other Q Number o Qng units: Number of bedrooms Character of sob th of 3 feat: Water table depth SEPTIC TANK ❑ fg Capacity No Compartments t,� PKG. TREATMENT PLT. ❑ Method of Disposal V Distance to nearest: el Foundation Property Line LEACHING LINE ❑ No. ngth of linea ength/size FILTER BED 0 rstanco to nearest: Well Foundation Pr ape SEEPAGE P A I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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." The applicant Mug call for all requ inspections. Complete drawing on reverse side, 7 Signed Title: 6e, lDate: / FOR DEPARTMENT USE ONLY Application Accepted by J___ Dste Area Pk or Grout Inspection by Date Final Inspection by , 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 `MOUNT DUE AMOUNT REMITTED C K H v♦1�RECEIVED /lBY DA/T�EI PERmi-r'NO. r EM 1124{11Ev, in 6i OQ EN 147e ! ✓ t+�� + ! J ,�3 -11P3 0 - r_- _,