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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ; P O BOX 2009, STOCKTON, CA 95201 (209) 468--3447 EMIT.-MIRES 1 YEAR 919 ld DATE ISUyJ9�2 (Complete in Triplicate) Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This application is made in comg,lianct with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of Ban Joaquin County Public Health Services. 1 Job Addressr �f �� City Lot Site/Acreage Owner's Name Cp_ i►��f lQI/ _ Address t C-11` .4. -S'o C, Phone Contractor lS I^t [ ' Address it J-S92 License No � Phon L TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES /-470' � DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL2-&&-L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ➢ ii 0 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excava on Dia. of Well Casing �Fomestic/Private C�Gravel Pack L7 Tracy Type of Casing Specifications Public C3 Other D Delta Depth of Grout Seal Ttpe of Grou t ❑ iib!t r U6 CJ Irrigation �..Approx, Depth ❑ Eastern Surface Seal Installed by � Repair Work Done U Type of Pump H.P. State Work Done , WAIT Destruction ❑ Well Diameter Sealing Material i Depth � Depth Filler Material i Depth TYPE Of SEPTIC WORK; NEW INSTALLATION Ll REPAIR/ADDITION M DESTRUCTION G (No septic system permuted if public sewer is C available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms _ f Character of soN to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, Ll _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ® No. & Length of lines Total length/size FILTER BED LI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance oto 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 reguiations of the San Joaquin County ` Home owner or licensed agent's signature certifies the following: "I cartify 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 sub-contracting signature candies 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-k tion laws of California." The applicant ust call for all required insPections. Complete drawing on reverse side, r f ! Signed X << ��/ Title: k� V c l�r Date: DEPARTMENT USE ONLY Application Accepted by r R Date i Area `yj Pit or Grout Inspection byData Final Inspection by Date Additional Comments: _S '��► t�r�� !/ Applicant - Return 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 IEEE AMOUNT DUE ' AMOUNT REMITTED CASH K If RECEIVED BY DATE PERMI7'NQ. r EH 13-24 IREV.I/N5i '0C_ - EH A-M