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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISIONAY �� ' 1 445 N SAN JOAQUIN, PHONE (209)4$8-3420 P O BOX 2009, STOCKTON, CA 95201 Receive, PERH T EXPIRES ]. YEAR FRQM DATE S SA -JOAQUIN 1 4 1993 i (Complete in Triplicate) ENUIRgLfC OL, ��HEAL7 SRU Ty Application is hereby made.to San Joaquin County for a permit to construct and/or install the tQr4 k�fJ& H ssIIE is application is made in comwliance with San Joaquin County Ordinance No.. 549 and 1862 and the Rules and ltegulationn d tr Joaquin County Public He Servicea. qAJ Job Address Umi&JAL City Lot Size/Acreage Owner's NameI Address -Phone + 1E ContractorA,__A�41Address License No. �_Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT�. DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C3, _ SYSTEM REPAIR ® OTHER ❑ Monitoring Well ❑ f DISTANCE TO NEAREST:_SEPTIC TANK SEWER LINES 1 _DISPOSAL FLD. PROP. LINE -�- _- F0' DA!TIQN--=- AGRICULTURE WELL' ="` OTHER.WELL ""-T-PITS/SUMPSr INTENDED USE ; TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -- ,- 0 Industrial .,❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack C1Tracy Type of Casing_ Specification s yllPublic ##-1 Other a n Delta Depth of Grout Seal ype of Grout I I Irrigation + _A i g pprox. Depth I I astern 1 Surface Seal Installed by 5 Repair Work Done ❑ :Type of Pump �_rH.P_;�_ State Work Doneh Well Destruction 0 [Welf Diameter Sealing Material i Depth ' �\ 3 Depth Filler Material.& Depth S TYPE OF SEPTIC WORK;f NEW INSTALLATION I I REPAIR/A11DITIQN_I lI p STRUCTION I I (No septic system permitted if public sewer is j •w r available within 200 feet.} Installation will serve: Residence f CommercialOther Number of living unite. Number of bedrooms Character of soil to a dipth of "3 feet: - __-_ _ Water table depth J SEPTIC TANK. (b .7?ype/l6lfg' 1 � Capacity No. Compartments PKG. TREATMENT PLT.❑ �" 3 Metfwd of Disposal . i 'Distance_to.nearest::Well. Foundation. _Property Line LEACHING LINE ❑ .No..& Length of lines Total length/size FILTER BED a Distance to nearest. Well Foundation' Property Line p SEEPAGE PITS IFI De th i p 5i:a Number SUMPS Gl IDistan6a to nearest: Well Foundation Property Line �e 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 3 rules and regulations of the San Joaquin County ; Home owner or licensed agent's nature certifies the following: t .. W sig g: "I certify that in the performance of the work-for which'etiis pirmit is-issued, E shall not employeny peso ' such'menner as to become subject to workman's compensation laws of Cafifornia."Contractor's biting or sub-contracting signature canities the fo ng '9 comity that in the performance of the work for which this permit is issued, I shall employ person"subject to workman's compensa- tion laws of : 1 The applica csll for all requir a inspaction )Complete drawing on rover do. Signed - M i Title: Date: r FOR DEPARTMEN USE ONLY d Application Accepted by 1 Date � � A Area _ Z- Pit or Grout Inspection by Date Final Inspection by Date r�,` Additional Comments: 1A U+/ NvwK � } ,. �d}.r /1 Ltp•:.,�l�y4tfd,�__r G ,..... ,r � �� Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services f 445 N .San.Joaquin, P-0 Hoa 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED K CEIVED BY 0#1E PERMIT'NrO. FM 14-26 a P �"