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n APPLICATI(r& FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT -E PIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or inst&U 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. �//A/ Job Address lt; 0 ! � �'v r� 4a City /eLot Size/Acreage Owner's Name 77;-144! /lel Address Phone Contractor 9(d1ress1 1 A License No. Phone /` u TYPE OF WELL/PUMP: NEW'WELL WELL REPLACEMENT n DESTRUCTION 0 Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. — PROP. LINE FOUNDATION AGRICULTURE WELL DOo OTHER /rV INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS //� / 1 Cl Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation / 6" Dia. of Well Casi C.A �+Q \ ❑ L]Dornestic/Private Gravel Pack Tracy Type of Casing_ 9 Specifications 1"1 Public 1-1 Other n Delta Depth of Grout Seal —Z1Q 17/ Type of Grout / e irrigation —Approx. Depth l I Eastern -Surface Seal installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if ZS-Oweravailable within 200 feet.)Installation will serve: Residence— Commercial_ Other Number of living units; Number of bedrooms Character of 604 to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Companmentst� PKG. TREATMENT PLT. ❑ Method o1 Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t � SEEPAGE PITS It Depth Size Number SUMPS Ll Distance to nearest: Well 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 subcontracting 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 st all al squired inspections. Complete drawing on r v; side. Signed / - - � Data: OR DEPARTMENT USE ONLY Application Accepted by - 3 C Date��—_ (� Area 'y� �` �• ��-• Pit Grout h pection by 144 Date s 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 AMOUNT DUE AMOUNT REMI .ED CK ECEIVED BY IN CASH DATE PERMIT NO. • EM13-24 1REV.11 n 5)W ' EH 14.7s