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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, 3TOCgTON, CA 95201 (209) 468-3447 NO V 2 6PERMIT EXPIREa I I YEAR gROM DATE L=.U�NVRONNIENTAL HEALTH i (Complete is Triplicate) PERW /SER BICE t - Applicstion is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application Is made in compliance with San Joaquin County Ordinance Ho.- 549 and ,1862 and the Rules and Regulations of San Joaquin County Public Health Services. (� Job Address LA 2A6,,6-i� City Lot Size/Acreage Owner's Name T� ��Address Phone Contractor Addfess Z 9_c--rOqw License No. Phone r TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Cl Out of Service well ❑ PUMP INSTALLATION 9�, SYSTEM REPAIR OTHER Q Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. _PROP. LINE l fOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS_ t! INTENDED USE' TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing ? V120 omestic/Private ❑ Gravel Pack ❑Tracy Type of Casing Specifications M Public i'l Other ❑ Delta Depth of Grout Seal Type of Grout CI Irrigation Approx. Depth ❑ Eastern lJ Surface Seal Installed by Repair Work Done -Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION L3 REPAIRIADDITION M DESTRUCTION G lNo septic system permitted if public sewer is - r e . r available within 200 feet Installation will serve: Residence.._,_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: --Water table depth 7-SEPTIC TANK ❑ - Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT.'0 Method of Disposal - Distance to nearest: Well foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total FILTER BED ❑ Distance to nearest: Well y Foundaii,jn Property.Line SEEPAGE PITS I 1 Depth Size Number "=-T__SUMPS = -LI_i.Distance.to nearest:- -Well -- .Foundation: - 'P_roperty.-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 t rules and regulations of the.San;Joaquin County Homs owner or licensed:bgem'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 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." _. -,�.. �. „^. 1.k `* - The applicant must II for all req 'rad inspections, Complete drawing on r rse side. y Signed Title: s Date: ! �'� f T ~9 Ap{ OR DEPARTMENT USE ONLY t Application Accepted by f Data A/I Area Pit or Grout Inspection by Date Final Inspection by Date. L ! Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P'O-BOX 2009, STOCKTON, CA 95201 INFE AMOUNT DUE AMOUNT AEM17..E�Oy_. --CASIis RECEEVEO 8Y flATE PERMIT'NO. Eye 13-24(REV.,r w si •(��e - -cit' fM;4•ts