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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR VROM DATE ISSUED (Complete in Triplicate) Application is hereby aide to San Joaquin County for a permit to construct and/or install the vork herein described. This application is onde in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. !jam �lo �/ /cl ,LOQ .�`� T/�..� cit age c Job Address y .�d.�,� Lot Size/Acreage d C Owner's Name hA� /4A,L1,f Address �/y Phone ` Contractor S �w Address J �} C 2, Icense No, _A6"44_ 'I 6 py/4 Phone TYPE OF WELL/PUMP: NEW VVELLA WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ I PUMP INSTALLATIONk SYSTEM REPAIR ❑ OTHER ❑ , Monitoring Well n DISTANCE TO NEAREST: SEPTIC TANK /ZD�� SEWER LINES DISPOSAL FLD. PROP. LINE 16 FOUNDATION _. _ AGRICULTURE WELL OTHER WELL PITS/SUMPS., INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS It 0 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation _f 2 Dia, of Well C"ng Domestic/Private _;Gravel, Pack ❑ Tracy Type of Casing, Sf>ecolica tionI- fz-&� ❑ Public 1-1 Other ❑ Delta Depth of Grout Seal _ Type of Grout _ CJ Irrrpatinn 3�lApprox.^Depth D Eastern �urfice Sea! Installed by Repair Work=Oone U Type of Pump , H.P. � SlMiVWork-pons Well Destruction Q Well Diameter Sealing Material A Depth Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/AOOITION 0 DESTRUCTION G INo septic system permitted if public sewer is available within 200 (set.) 1 Installation will "rye: Residence Commercial- Other ; Number of living unite Number-of bedrooms I yyy� Character.of soil'to a depth of 3 feet: Water table depth SEPTIC TANK r_O Type/Mfg - Capacity No. Compartments y PKG. TREATMENT PLT,❑ t --�-� Method-of Disposal I t D41ance'to nearest: Well - Foundation Property Line # LEACkING LINE �Cl No. 8 Length of lines - Total length/size FILTER BED O Distance to nearest: WellFoundationI Property Line SEEPAGE PITS i I Depth Sire_ Number SUMPS `. LI Distance to neatest:-Well Foundation Property Line DISPOSAL PONDS r -❑ 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 I rules and regulations of the San Joaquin County 1 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 shell not employ any person in such manner as to become subject to worflman's compensation laws of California."Contractors hiring or sub•contrecting signature certifies the following: "I Certify that iii-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 mu r, owed ins Complete drawing on ree iqe r Signed X� . /� 'O"Thle :vers7Date: T-g FOO EPARTMENT USE ONLY Application Accepted by % Date 1^ Area_ 12- Pit or ro Inspection by ate _ Final Inspection bye Data ' / r Additional Comments: JI Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT Dt1E AMOUNT REMITTEDCK CASH RECEIVED By DATE PERMIT NO. . EH 13-24IAEV. /As) �7