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APPLICATION FOR PERMIT 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 I YEAR FRQM DATE (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 in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 2,6 City Lot Size/Acreage Owner's Name Q��Q�rLcr� r' _ AddressLLJ2-O '+ Phone t' I Contraclor 1 r11t t Address &Ze 't License No.5_1�.Phone '�`�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service well ❑ a PUMP INSTALLATION O SYSTEM REPAIR ❑ 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 0 Industrial D Open Bottom E3 Manteca Die. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public f'1 Other ? n Delta Depth of Grout Seat-Y Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal installed by d i Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction Well Diameter ri Sealing Material & Depth Depth �+{'y 1►iller Material i Depth w TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence Commercial Other Number of living units: Number of bedrooms Character of sod 10 a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PITT. ❑ r Y Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size , FILTER BED ❑ Distance to nearest: Well Foundation Property Lina ,tet 4 SEEPAGE PITS I I Depth Size Number lI' SUMPS L1 Distance to 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 regulations of the San Joaquin county Homs owner or licensed ant's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shad net ge 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 laws of California." The applicant st cad-f all iced ins ns. Complete drawing on reverse side. Sigrw J Title: Date:V 13W - ' FOR DEPARTMENT USE ONLY Application Accepted by Data ••�~ Area Pit or Grout Inspection by Date Final Inspection by A Date �Z Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY BATE PERmrr'NO. INF,�O/q� am Q EH /y 17-3 tREV.�i�51 W1} Ute' &0 �'D� !�— -5 + EH if-� ii// A