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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 i (209) 468-3+ff.3qD-0 a PERMIT Mlgga I YEAR ERQMi PATE ISSUED (Complete in Triplicate) Application is hereby riade to San Joaquin County for s permit to construct and/or install the work herein described. This application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County public Health Services. I Job Address 7 City Lot Size/Acreage X 40 Owner's Name 9.11 Address Address Phone OL Z � c Contractor Address License No-2-5 k I Phone TYPE OF WELL/PUMP: NEW WELL ID WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 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 E n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications CI Ptiblic I'll Other ❑ Delta Depth of Grout Seal Type of Grout f CI Irrigation Approx. Depth 0 Eastern Surface Seal Installed by ' Repair Work Done..-0- Type of-PumpH- - -Work-Done -4— Well ! Destruction ❑ Well Diameter Sealing Material i Depth E t � Depth —p r 44 . � Deth i z s TYPE OF SEPTIC WORK: NEW INSTALLATION 0 fn0A1FMFtJIf ,> T of -114c system permitted if public sower is t M it I awithin'200 feet.) Installation!.will serve: Residence _ Commercialhave lux- ,, + ! ) Number of,living units: Number of bedrooms t-D ) i�ed . but Character of soil to a depth of 3 feet: Y 1 44 r i afar table depth SEPTIC TANK. ❑ Type/Mfg ` CaptaLVU iq No. Compartments t ) PKG. TREATMENT PLT. 0 `' fam } of fl ►S 'Method of Disposal t Distance to nearest: Well Foundation _ Property Line + ; 01 LEACHING LINE L1 " L No, 8 Length lines d �f f i g Total lengthlsi:e ' FILTER BED n Distance to ndarest: Welly 01-1oundation f Propeny Line r I SEEPAGE PITS I I Depth �,' _Si:a # Number F I SUMPS 1 ! L1 Distance to n6arest: Weit, Foundation �t Property Line 'r F DISPOSAL PONDS ❑ It ; I hereby certify that I have prepared this appiication_and-that,the work will be done in accordance with San Joaquin county ordinances; state laws, and 'rules and regufatioiis`of iK6 Sash Joaquin County ! i - "Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is itisued, I shall not afi)ploy any parson in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or subcontracting signature certifies the following: "I cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman'!'compensa- tion laws of California." i. 1 i The.applicant must_call_Ior-;F"4b ired_in ctions'_Compiete..drawing-on-reverse-nidal-•- - - - - - -- ---� -- i SignedTitle- _ ''� Date' F DEPARTMENT USE ONLY _t J., I Application Accepted by ` ---,.Date.. ._ '" r -'1 , ____ Arsa_ . k 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 PERNIT/SERVICES - ' 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 + i INFE AMOUNT DUE AMOUNT REMITTED CASH CK f fiECEIVED BY DATE PERMIT NO, INF�. EM,`'� IPtY.i,rt>> 2 Y'L At -2 `7 031 i