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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 EXPIRES 1 YEAR PROM DATE INSUED (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 Cowllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Heeaal,�,th Servicecs,., Job Address `—��i��D1L CitClerO Lot Size/Acreage Owner's Name I e–t Address –90 141 Phone Contfactorgck_., Address ROVS10S S'tKA-) ?zS&> License fVo.sZ1 Phone TYPE OF WELL/PUMP. NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Nell Cl PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER © Monitoring Well El 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 O Manteca Dia. of Well Excavation Dia. of Well Casing 9.Domestic/Private, - -El Gravel-Pack L7 Tracy Type of Casing Specifications M Public Y Cl Other © Delta Depth of Grout Seal Type of Grout G Initiation �.Approx. Depth ❑ Eastern + Surface Saul Installed by PF Repair Work Done 0 Type of Pump H,P, _` State Work Done r/ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G iNo septic system permitted it public sewer is favailable within 200 feet.) 4 Installation will serve: Residence Commercial-;.— Other Number of living unite: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments j PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. n Length of lines Total length/size FILTER BED - D Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line w DISPOSAL PONDS O 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 sub-contracting 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 Iowa of California." The applicant must all for all require spec ions. Complete drawing on reverse side, Signed Title: Z—" — Date: OR DIMARTIMENT USE ONLY Application Accepted by Date < Area Pit or Grout Inspection by Date Final Inspection by 1 '`�✓ �` Date Additional Comments: Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMrTTED CASH Cx If RECEIVED BY DATE PERMIVN^O. . EH 17-24 tREV.I/n 5! O t'.H 114-20 %d� t t� 7 Z { �- o f