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APPLICATION F6R PERMIT a SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 i P O BOX 2009, STOCKTON, CA 95201 PERMIT EXP RES 1 YEAR FROM DATE ISSUED (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 is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San 1 Joaquin County Public Health Sery cos. I t^C� City Lot Size/Acreage Job Address Address Phone M UOwner's Na p/� � nt�� yL� �Uat"�'P ense No.�i� Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ �� Monitoring Well ❑ PUMP INSTALLATiOlN,;�/-� SYSTEM REPAIR ❑ OTHER ❑ 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 Dia. of Well Casing n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Specifications ry Type of Casin ' mastic/Private ❑ Gravel Pack C] Tracy g i1 Public 11 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. De pth tern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. _ State Work Done Sealing Material & Depth Well Destruction ❑ Well Diameter Filler Material i Depth Depth 4 0 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I available within 200 permitted �! public sewer is -^ Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms �? Character of$OM w a depth of 3 fest: Water table depth SEPTIC TANK O TypslMfg "^,.Capacity i No. Compartments t� Method of Disposal t P PKG. TREATMENT PLT. ❑ J Distance to nssrest: Well Foundation— Property Line : LEACHING LINE L1 No. b Length of lines Total length/sire FILTER BED ❑ Distance to nearest: Well` Foundation Property Line 1 7% '< i SEEPAGE PITS Ji Depth Sire Number SUMPS LI Distance to nearest: Well a :Poundal on t Y Property Line Q DISPOSAL PONDS_ ❑ fI hereby certired this application and that the work will be done in accordance with San Joaquin county ordinances, state laws fy that I have prepa , and rules and regulations of the San''Joaquin_County___,.,;,_ --.�—� �-» �—� Home owner or licensed agent's iignsture osrtifies the following: "1 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."Contractot's hiring or subcontracting signature certifies the following: "i certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's eompsnss- tion laws of Cal' nta." The ar"o t call uir inspections. Complete drawing an raver ide. i Sig Title: Date: FR DEPARTMENT USE ONLY Application Accepted by Date.TC1 ".Z Area iDate Final inspection by 10, Date Ook Pit or trout Inspection by Additional Comments: L Applicant - Return all copies to: San Joaquin County Public Health Servicers f Environmental Health Permit/Services 445 N San Joaquin, P O Box-2009, Stkn, CA 95201 WEEUE AMOUNT REMITTED CASH RECEIVED BY GATE PERM17'Np. �14111 -3093.EH 14•2a k-