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� `€ g APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NOV 2 ENVIRONMENTAL. HEALTH DIVISION ,t -JFALJI� O BOX 2009, STOCKTON, CA 95201 N�� rl�'i (209) 468-3447 PER - YEAR (Complete in Triplicate) Application is hereby made to Sen Joaquin County for a permit to construct and%or install the work herein described. This application is made in cotspiiance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. J Job Address o• City Lot Size/Acreage Owner's Name U=C&=LAddress Phone ConlraUor; Address , O�q icense Noo3 Phon -��16 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION .1.;SYSTEM REPAIR> ' OTHER ❑ Monitoring Well E7 ' DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION w AGRICULTURE WELL OTHER.WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d — - n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing VDomesticlPrivateLl Gravel Pack ❑ Tracy Type of Casing Specifications. M Public is Other 0 Delta Depth of Grout Seal Type of Grout 0 Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by h Repair Work pone Type of Pump H.P. a— _.� State Work Done 7J CI Wall Destruction 0 Well Diameter Sealing Material & Depth v Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION M DESTRUCTION G ]NO septic system permitted if public sewer is available within 200 feet.) (, Installation will serve: Residence.� Commercial Other w Number of living units: Number of bedrooms Character of coil to a depth of 3 feel: Water depth { SEPTIC TANK. O Type/Mig Capacity �. �No. Compartments PKG. TREATMENT FLT. ❑ ,.. '" —Method of Disposal Distance to nearest.:, •,Well Foundation Property Line. f LEACHING UNE C] No. & Length of tines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS I I Depth Size Number SUMyPS Cl Distance to nearest: Well Foundation Property Line fr"-DISPO5AL 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 Countyy 4 k Home owner or licensed agent's signature certifioii the`followirig: "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 6 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 must a41� 11 requiredtins tions. Complete drawing on averse side: Signed �U Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by �,A1 Date Area Pit or Grout Inspection by Date Final Inspection by Date 1.2- r7 . `t d 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 2009, STOCXTON, CA 95201 FEE AMOUNT DUI: AMOUNT REMITTED CK f- IWO Y 5 ASH RECEIVED BY DATE PERMIT'NO. + EH 13.24 IRIV, EM I-•26 1 (1 T i