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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 t � DTiR1i T rt` .exp I RES 1 YEAR I�. OM DATE XsM �1� �� 1 (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 madesin compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. re22 V City'4AO�t Size/Acreage Job Address A — Phone i Owner's No Address r-�:- �sZp� S / — License No, ____ ��--Phone Contractor Address TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service ue11 ❑ _ PUMP INSTALLATION 0 -REPAIR .D .OTHER Oa., Man or ng w �� i.t Well J DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP70NE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing l rl Industrial ❑ Open Bottom Cl Manteca Dia, of Well Excavation Type of CasingSpecifications U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Grout M Public 1-1 Other ❑ Delta Depth of Grout Seal CJ Irrigation ,_._..Approx. Depth ❑ Eastern ,£Surf Ice-Saal Installed by Repair Work Done U Type of Pump H.P. Stats Work Done _ Well Destruction ❑ Well Diameter sealing Material i Depth Depth Filler Material i Depth C i public sewer is N Ll DESTRUCTION [No septic system permitted I p TYPE Of SEPTIC WORK: NEW INSTALLATION fl REPAIRIADDITIO available within 200 feet.) 11 Installation wili serve: Residence— Commercial Other ? v 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 PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L-I No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line .. � 4 SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS0 I hereby certify that I have prepared this application and that the work will be done in.accor ance with San Joaquin county ordinances, stela laws, and rules and (aguiotione of the Sen Joaquin County t 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 certifles the following: "I certify that in the parformance of the work for which this permit is issued, I shall arnploy,persons subject to workman's compenso- lion laws of California." The app' us all for all required in ctions, Complete drawing on reverse side. ^� Signed Title: ' — ��'� . U Daie: OR DEPARTMENT USE ONLY _ Application Accepted by f Data ^ Area Z��II - FieW I 5,. • _711<11! LrHlY j ►�{Y. r/�{ a Tomer f Pit or Grout Inspection by Date Final Insp c((lon by_ a °N^� - ate u)4s Zee l Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 FE£ AMOUN7 RIFE AMOUNT REMtT-TED CA5H RECEIVED BY DATE PERMP No. INFO . EM 13.24IRev.�/as) Wo s, t L-f L v�aJ� EMA-26 - .