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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 0 BOX 2009, STOCKTON, CA 95201 PERMIT MIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in cotopliance with San Joaquin County Ordinance No. 549 and 1862 and.the Rules and Regulations of San Joaquin County Public Health Services. It JR Job Address '� �' � Sir' T7,41r'L-� nG! City 7RI( EC-4 Lot Size/Acreage Owner's Name /_�C(' 11 Address Phone Contractor Nr all Address ZOQ,7 lot v*s of w "Ver'—License No. IVY ov!�• 'Phohe TYPE OF WELL/PUMP:: .NEW WELL-O_. WELL REPLACEMENT ❑ DESTRUCTION.Ll Out of Service Well ,❑ k PUMP INSTALLATION ❑ SYSTEM_ REPAIR ❑ OTHER ❑ Monitoring Well ,n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r" FOUNDATION AGRICULTURE-WELL, OTHER WELL PITS/SUMPS 10ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Fl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing— Specifications F1 Public Cl Other Fl Delta Depth of Grout Seal Type of Grout I l Irrigation —.Approx. Depth I 1 Eastern �Suriace Seal installed by Repair Work Done L] Type of Pump H.P. State Work Done Y 4Q Well Destruction ❑ 'Well Diameter' Sealing )fstet=lal i Depth Depth Filler Material i th TYPE OF SEPTIC WORK:, NEW INSTALLATION I 1 REPAIR/ADDITION, :+ DESTRUCTION l I iNo septic system permitted if public sewer-.is +j 4 available within 200 feet.) Installation will serve: Residence L Commercial_ Other Number of living units: __L_` Number of bedrooms Character of soll to a depth of 3 feet: '„ . Water table depth SEPTIC TANK: ❑ Type/Mfg Capacity No. Compartment' i PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well .Foundation t' Property Line t � LEACHING LINE LI No'& Length of linea Total length/sue FILTER BED Jq Distance to nearest: Well _ Foundation Property'Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑. ' i 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 sub-contracting signature certifies the following: "I certify dist in the performance of the work for which this permit is issued, I shell employ persons subject to workmen's compensa- tion laws of California." k The applicant must call for all required Inspections. Complete drawing on reverse side. Signed X Title: Date: R DEP TMEN J!l.L.Y_-. 1 F Application Accepted by Date resf� Pit or Grout Inspection by Data Final inspection by Dater" Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE1 INFO AMOUNT DILE iAlMO NT REMITTED SH RECEIVED BY D TTE I PERMIT'NO. . EH I4.24 PREY.iirsi EH i4•Ia i y