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' APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 MAR 1 8 192_'1 (209) 468-3447 ENVIRONMENTAL HEAL I; PXMIT EXPIRES 1 YEAR PROM DATE la�UED (Complete is Triplicate) PRMiT/ UG ES Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is Slade in cotVllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Publi Health Services. p� e� Job Address _ [n / r �-_ �LLdCE1L6d1LX-�' F-•- City Lot Size/Acreage Owner's Name Address Phone (?Z&-0I 0 a77;6 Ctlnlfa Or �s LteCM1se No. G V Phone TYPE OF WELL/PUMP. NEW WELL 0 WELL REPLACEMENT fl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM R€PAV OTHER p Monitoring Well C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack C1 Tracy Type of Casing `� Specifications M Public ("I Other ❑ Delta Depth of Grout Seal Type of Grout G Irrigation Approx. Depth ❑/Eas orn Surface Soul installed by. Repair Work Done 0 Type of Pum �iG'— H.PC _ _ _ __ State Work Done Well Destruction O Well Diameter j6 Sealing Material i Depth Depth biller Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION CT DESTRUCTION CI tNo septic system permitted it public sewer is 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 SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. S Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property 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 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 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- tion laws of California." The applies ust call jar ell required inspectionomplete drawing on rav se side. S igr d 2 dL ,Isi_ Title: Date: OR D,§PARTMENT USE ONLY Application Accepted by 04Date ( Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES -_`t` 445 N SAN JOAQUIN, P 0 $OX 2009, STOCKTON. CA 95201 SRO INFO FEE AMOUNT DUE AMOUNT REMITTED [ASH RECEIVED BY DATE PEAMII'N0. t f 13.24(A EV.i/MSI �.] 1! 1 I91 -64 FH 11.20