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APPLICATION.-FOR PERMIT f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 . PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in hereby made to tion Joaquin County for a permit to construct and/or install the work herein described. This application is made in coaspliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Sery es. or �� + . / ,� �' C Job Address / City ,e�(��' /�-r �• Address S l� / Phone �� l Owner's Name ! _ F Contractor � Address 2 License No.4 O Sw�__Phone service Well L-1 77PE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION 0 Out Mona ring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial -❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i T of Casin Specifications. I-1 Domestic/Private . ,❑ Gravel Pack ❑ Tracy Type g- 1'I Public . I-1,Otherti n Della Depth of Grout Seal Type of Grput_ \\ I I Irritation ` ,-Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Typo'-of Pump H.P. Stat*Work Done Well Destruction ❑ WeII Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i DESTRUCTION lNo septic system permitted it public sewer is available within 200 feel.) i Installation will serve: Residence-t!"'Commercial Other � � �4 Number of living units: Water ta6k depth : Number?o brooms _ ' Character of soil to a depth of 3 feet: U-! SEPTIC TANK. C9—f ype/Mfg Capacity No Co mpartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well 49 C -""Foundation Property Line . 2> eco Total Leri thlaize -� 1 LEACHING LINE L4--No. 8 Length of lines g FILTER BED ❑ Distance to nearest: Well- SEEPAGE ell Foundation 3 1 Property Line --6 4 SEEPAGE PITS 14,16apth �5� Sire y �nNumber ¢ .�� SUMPS . CI Distance to nearest: Well - Foundation I 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, stats laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following; 111 comity 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 sppfi call for all req ed ins ctions. Complete drawing on reverse side. _. -«, ,» Title: Cf� Date: S re 4 I,-- F F R DEPARTMENT USE ONLY ` Application Accepted by Date�' fl Area Z y Z Pit or Grout Inspection by.� Date Final Inspection by pets Additional Comments: Applicant - Return all copies to: - San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. INFO AMOUNT DUE f�/ H a EM 53-t4 tItEV.I/N Sl Err 14.36 _ - -