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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PEMIT EXPIRES 1 YEAR FROM DATE ISSRED (Complete in Triplicate) Application in hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is grade in cor'liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. t �7 � A� Job Address Z / / �� City DL'� �t Size/Acreage /� _. _ Address Phone ` S ! S/ Owner's Name � �1 Z GG ,� �773d'S . 3"3 y`y7Z1� Contractor 1 T /�Jtf Address ,_0 7 License No. Phone Of TYPE OF WELL/PUMP: NEW WELL fad WELL REPLACEMENT DESTRUCTION Out Mo onServSce Well ❑g Well L7 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Mitorin DISTANCE TO NEAREST: SEPTIC TANK f:� SEWER LINES DISPOSAL FLD.I10 PROP. LINE 10 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS !i i i. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i Cl industrial ❑ Open Bottom ❑ Manteca Die, of Well Excavation !"t Dia. of WelllCasing Y�J cpomesticlPrlvala �LGravel Pack 0 Tracy Type of Casing_ y��- Specifications.. = a I'1 Public 1-1 Other r �wlfl Delta Depth of Grout Seal Type of Grout C& I I Irrigation 1.a2 Approx. DBpRtt— I I Eastern Surfale Seal Installed by s s Repair Work Done U Type of Pump � H.P. -_� _ State Work Done Well Destruction ❑ Well Diameter G; Sealing Material i Depth ctla e.y Depth S`y Piller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I pESTRUCTION I 1 INo septic system permitted it publicsower is }} available within 200 feet.) Installation will serve: Residence_ Commercial_ Other �. Number of living units: Number of bedrooms o '� Character of sob to a depth of 3 feet: ti 1 ` `'< Water table depth ❑ TyeMfg -- CJa '6�t`ySEPTIC TANK Nm-Compsi tmsts PKG. TREATMENT PLT. ❑ i Method of Disposes t Distance to nearest: Well _T Foundation Property Line i .fit+ LEACHING LINE ❑---Nom b Length I1•Imes Total Length/size FILTER BED ❑ Distance-eo--AsaresS i Weil Foundation Property Line 1 /� SEEPAGE PITS, 11 Depth Size r Number i SUMPS i 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 Sari Joaquin County Home owner or licensed agent'ti 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 manners=fo`beoome subject'to workman's compensation laws of California." Contractor's(tiring or sub>contracting signature certifies the following: "I unify that in the performaries 2611 the work for which this permit is issued, I shall employ persons subject`to workman's compensa- tion Iowa of Californla." 's A The applicant m.us ca or requi inspections. Complete drawing on reverse side. Signed X. ( . _- Title: � Date: % 3J�Z R DEPARTMENT USE ONLY t Date a) Area Application Accepted by f Pit or Grout Inspection by ;ate 1$ 2- Final Inspection byAdditional Comments:C 6`Applicant- Return a copies to: San quin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 ' FEE AMOUNT DUE AMOUNT REMITTED I K RECEIVED BY DATE PERMITNO. INfA CASH w q �y - {�' � $2_ L!013 - L101Z • EH 1321 fRtN,I/x5) EH 11.2a i&L kpl*1 .2 �,f 0 1 L/