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APPLICATION FOR PERMIT SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 �p i DTiR1�T'I` IRE§ X YEAR ,E ISSM i (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 to made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Reguilations of San `Joaquin County Public Health Services. I City L- �—- Lot Site/Acreage Job Address ,I ' Owner's Name te2f�L.� !C1 rNf� ,A Address 12& a Shone hh Contractor Address l Phone License No. TYPE OF WELLlPUMP: NEW WELL Cl WELL REPLA EM N ESTRUCTION ❑ t of Service Well ❑Monitoring Well well r 1 PUMP INSTALLATION ❑ SYSTEM REPAIR C7iER /�/��,5 Wk(f7 1 it DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. DP. Llrrcp j FOUNDATION AGRICULTURE WELL OTHER WELL 'PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i Dia. of Well Excavation Dia, of Well Casing 11 industrial ❑ Open Bottom ❑ Manteca U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public I'1 Other 0 Delta Depth of Grout Seal Type of Grout I� CJ Irrigation Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Welt Destruction 0 Well Diameter Sealing Material i Depth j Depth Filler Material i Depth 4 TYPE OF SEPTIC WORK: NEW INSTALLATION JO REPAIR/ADDITION 0 DESTRUCTION G iNo septic system permitted if-public sewer is �V available within 200 feet.l I C installation will serve: Residence— Commercial— Other I Number of living Unita: Number of bedrooms jl Character of soil to a depth of 3 feet: Water table depth EEE SEPTIC TANK. ❑ Typ@ Ig Capacity_,.. No. Compartments Ij Method of Disposal PKG. TREATMENT PLT. ❑ !M Distance to nearest: Well Foundation Property Line II LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED 0 Distance to nearest: Well Foundation Property Line I` SEEPAGE PITS 11 Depth Size Number j 4 SUMPS LI Distance to nearest: Well Foundation Ptoperty Line r I r DISPOSAL PONDS D I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordina`ncas, state laws, and rules and regulations of the San Joaquin County ik Home owner or licensed agent's signature cenifies 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 subcontracting 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- 1 tion laws of California." '� The applicant ust tail for all•requir inspsc ' na. Complete drawing an r verso nide. �I Title' ` � �� ' Date: .�T or Signs- .' ENT USE ONLY i Application Accepted by 11 S dJ 6vr c�r7r Q-�f k Pit or Grout Inspection by Date Final spection by YI r�v6 ate Additional Comments,, r i` Applicant ^ Return all copies o: S IN COUNTY PUBLIC HEA TH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 945 N SAN JOAQUIN, P D BOX 2008, STOCKTON, CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. ' INFO y- • EH 13•24IREV.s/n51 - EH Vv f it