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APPLICATION FOR PERUIT 'Wi SAN} AQUIN COUNTY PUBLIC HEALTHRVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES- 1 YEAR FROM DATE ISSUED . (Complete in Triplicate) Application is hereby made to San Joaquin County for a perrblt to construct and/or install the work herein described. This application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ' Job Address �' "'D� i�OLr _ City 71=t,*-ILN't Lot Size/Acreage Gtl4, - J�/"Ll i- Add '1 'r5f/ ✓�� JT ICt Phone IVY-"4/J Owner'a Name Address 7! Contractor / �+ /j61<' r (eCC ?a .Address PC' 00 76 �'U �L' License No. � `7-/ r! Phone Zt w37'L3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C1OT.HER Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PjTSJSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack* L7 Tracy Type of Casing_ Specifications 1'I Public 1:1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done L1 Type of Pump H.P. a State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth hiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I t DESTRUCTION I I INo septic system permitted it public sewer is available within 200-feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms. Chewier of soft to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT, C1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L`1 No. 6 Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L.1 Distance to nearest: Wet] 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 of licensed agent's signature certifies the following: "I certify that in the performance of the work tot which this permit is issued, 1 shall not employ any person in such manner as to become subject to workmen's compensation laws of California," Contractor's hiring or Siub-contracting signature certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Iowa of California." The applicant"just cap f r In' ui(aa i paclions. Complete drawing on&verse side. � 95r ` rp , Signe � Title: 't F R DEPARTMENT USE ONLY r_ Application`Accepted by Data �J Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ( Environmental Health Permit/Services J�) 445 N San Joaquin, 1) O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. CASH SH /� 9� C • EM 13.24 114(V. 51 G�S77 Y Z �J/� !-+ Q✓ 3I EH 14,26