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APPLICATION FOR PERMIT , SAN JOAQUIN'COLPNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P OsBOX '2009, STOCKTON, CA. 95201 (2091) 468-3447 it IT YEAR PRQ9 DATE ISSUED (Comp'le a in Triplicate) jYr Application is, hereby Made." San Joaquin County for npperrnit to construct and/or install the vork herein des -i � Thita application is made in comwllance vith Ban Joaquin Couiity;:prdinance' No. 549 and 1862 and'the Rules and .Regulations of San ` Joaquin County Public Health Services. r Job Address .}a n r 9 f ° cityS"C.,Z-tnu Lot size/Acreage Owner's Name Address Phone ContraUor tf� �- j ta�'l�P, ? __ Address �S License No. Phone w.9___•._�..._- i_-.__.--- T.YPE-OF-WELL/PUMP:._... ___, _ _._..-NEW-WELL-C) ..,W_.ELL REP_LACEMENT_;.0_,__,DESTRUCTION 0-.Out_of Service Well Cl . PUMP INSTALLATION ❑ SYSTEM REPAIR C1OTHER❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK _.__ SEWER LINES DISPOSAL FLD, PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 171 Industrial ❑ Open Bottom ❑ Manteca Dia;of Well Excavation Dia. of Well Casing U Domestic/Private ' L1 Gravel Pack n Tracy Type of Casing � Specifications _ M Public ill Other ❑ Delta Depth of Grout Seal _ '-- Type of Grout Gi Iriigation __ Appiox, Depth ❑ Eastern Surface Setil Installed by R Repair Work.Done ''U Type of Pump v ,. H.P. State Work Done Well D*struction ❑ Well Diameter Sealing Material i .Depth " Depth Filler Material,& Depth. TYPE OF SEPTIC WORK: -NEW INSTALLATION Er REPAIR/ADDITION G1 ;DESTRUCTION M INo septic system pe'rmigtid if public sews( is # available within 20.0 feet.) I stallation will some: Residence ICommerciai Other Number of living units: 1 Number of bedrooms _ Character of soil to a depth of 3 feet: ck�abnsd -Water table depth SEPTIC-TANK �nG• Capacity _-.No.'Compartmenta PKG. TREATMENT PLT:. ❑ .'__.' + Method.of._0 , t Distance to nearest: Well Foundation J. Property Line- LEACHING LINE ,V"0 Nd.A Length of lines �� -i:�} Total lengtK/size t l FILTER BED (:1 Distancelto nearest: Wall' ,J•.,�.�` !' f=oundation �- ''T.,Property Line I _" SEEPAGE PITS { { I pis pth Ft " Size ____�� i t pl'•-.}[ f-w_ `Number." l } SUMPS ; Dista to nearest: Well_ ,? Foundation F Property Lina DISPOSAL PONDS I I hereby cortify-1hat'i have prepared 1his`applicalr6 and that the work will be donp,in accordance with San Joaquin county ordinances, state laws, and rules and,regulationa of the San Joaquin County Home owner or iicensed'egent's signature certifies the following: "I cartity that in the performance of the work for which this parmit is issued, I shall not ploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 'i dertifies the following; ":',certify that in the performance of the work for which this permit is issued, i shall empioy persons subject to workman's componsa- •tion Iowa of California."t , � }t 4 The applicant must call for all requirAd inspections, Corinplete-drawing An reverse side, i Signed ` Title: Date: FOR DEPARTMENT USE ONLY i Application Accepted b RP P Y Date Area Pit or Grout Inspection by Date Finer Inspection by Date _ Date I Additional Comments: Applicant -.Retura.all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH_SERVICES ENVIRONMENTAL HEALTH DIVISION.PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 1,FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE f*5�1 /P�-ERMII'N0. . EM 1344 IrrEY.I/N 31 �i/ �/ 0_421�. EH 1{•24