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t APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES:; ENVIRONMENTAL HEALTH DIVISION ,4'w P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 JAN 2 5 SIT E%PIRTS_]_YEAR ]?ROM DATE iskjaViRON€MENTAL H1_,ALTfF3 (Complete in Triplicate) PERMIT/OERviCEIS Application is hereby oade,to San Joaquin County for a permit to construct and/or install the vork herein described. This application Is 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 �a `f" I-rGrri City Lot Site/Acreage Wa4 Owner's Name&l Tihommu- rawl- Phone(W _ j gnt�ss Contractor .. �� kV=.Ld- License No. hone SZI TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION D SYSTEM REPAIR OTHER 0 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 - M Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing �omesticIPrivate ❑ Gravel Pack C3 Tracy Type of Casing_ Specifications I M Public 111 Other ❑ Delta Depth of Grout Seal Type of Grout CJ Irrigation ._,._..Approx, Depth 0 Easterndace Saul Installed by Repair Work Done .(ly Type of Pump H.P. State Work Done Qum PfAdmall Wall Destruction O Well Diameter (O Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIWADDITiON 0 DESTRUCTION CI lNo septic system permitted if public sewer is available within 200 last.) Installation will serve: Residence___. Commercial Other Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. - - ❑ -Type/Mfg Capacity No. Compartments PAG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE ❑ No. & Length of lines v Total length/sire I FILTER BED n Distance to nearest: Well Foundation ` Property Line SEEPAGE PITS I I Depth Sire Number { SUMPS LI Distance to nearest: Well Foundation Property Line YCJ —DISP_O.SAL_PONDS—__D a 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 laws of California." The applic t�ast call to ala uiredAnspwtions. Complete drawing on re se side: AMSigned Title: Date: # FO EPARTMENT USE ONLY / Application Accepted by Date Area Pit or Grout Inspection by Y Date Final Inspection by Date 740-191 Additional Comments: _ I Applicant - Return all co les to: I P SAN JOAQUIN COUNTY PUBLIC HEALTH 9I'sRVICE5 ENVIRONMENTAL HEALTH DIVISION PEPJIIT/SERVICES ' 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNTDUEAMOUNT REMITTED GASH CK S RECEIVED BY DATE PERMIT NO. . EN 1I.741REV,v/N51L9�' EH;{•se C:.Ii.Jt 1 I k � � l,(� r