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APPLICATION FOR PSRIdIT , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION b 45 = 8AN JOAQUIN, PHONE (209)468-3420 % 2009, STOCKTON, CA 95201 -/PARMIT EXPIRES 1 YEAR FROM DATE I SSUED (Complete in Triplicate) Application in here? > a iv ubty for a permit to construct and/or install the work herein described. This application is made m ss�""';," oaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Count Public e f L Job Address � c .S7YRt'� __ City S4G�/`� ', Lot Size/Acreage Owner's Name r 1�7TJn Address lYkS_ %740117 Ctf phone i Contractor f�,'7F5c Address 20 &XI464( License No, Phone II� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT R DESTRUCTION ❑ Out of Service Well ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER s-dOf �Well [] 4 DISTANCE TO NEAREST: SEPTIC TANK /V7`A-••— SEWER LINES AeZ,& DISPOSAL FLD,&�IA PROP. LINE 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 CasingAZA F.) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-- Specifications I.1 Public VT Other (l Delta Depth of Grout Seal Type of Grout � t 1 1 Irrigation _Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ❑ Type ypa of Pump H.P. State Work Done� k Weli Oestfuction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADOITION I 1 DESTRUCTION I l lNo Septic system P permitted if public sewer is available within 200 feet.l QsWis,on will serve: Residence^ Commercial— Other Number o units: Number of bedrooms Character o1 and to a feet: SEPTIC TANK. Water table depth , ❑ Type/Mfg city No. Compartments I ,. PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Foundation Property Line `} LEACHING LINE ❑ NO. b of lines Total length/size- "" ength/sire € ' FILTER BED ❑ once to nearest: Well Foundation Property Line SEEPAGE PIT I I Depth Sizef Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rubs 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 became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the pertormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lawn of California." i The applicant m t Q811 for all requirV inspections. Complete drawing on reverse side. Signed - _ Title: /._Y.A Date: FOR DEPARTMENT USE ONLY f.� Application Accepted by �L t V` Date 1- 0-93 Area 1��„__,� Pit or Grout Inspection by Date Final Inspection by Data Additional 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH1}7t(REV.1 i R 5) g EH 117E