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r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Ivo� ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 9520 . NO ' (209) 468-3447 / + PERMIT 73XPIR88 1 YEAR FROM DATE__ISSUSD (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct end/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and-1862 and the Rules amd Regulations of San Joaquin County Public Health Services. p Job Address City Lot Size/Acreage 7,S /UCS i Owner's Name IL Address Phone 6-4 �'j�'T7 c c - u 0-7- Contractor Address License No. Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Wall Cl j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE onitoring well 0DISTANCE TO EPTIC TANK SEWER LINES DISPOS PROP. LINE FOUND AGRICULTURE WEL THER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PRO CONSTRUCTION SPECIFICATIONS M Industrial C] open Bo ❑ Manteca Ora. ell Excavation Dia. of Well Casing i U Domestic/Private ravel Pack C1 Tracy Type of Casing Specifications M Public I:1 Other © Delta Depth of Grout Seal Type of Grout s M gation Approx. Depth Cl Eastern Surface Se Installed by Repair Work Done v Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth / Depth biller Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ID REPAIR[M' KC REYee rmitted if public sewer is E1t.l Installation will serve: •Residence— Commercial r Other Number of living units: Number of bedrooms �Permft' may have RPM Without ' Character of wit to a depth of 3 feet: Tttau 'Water table depth SEPTIC TANK ❑ Type/Mfg worI pact Y or inSP9 "artments L PKG. TREATMENT PLT. Cl Y Ln nm-, --'al Health DiV of Disposal �d Distance to nearest: Well Foundation. Property Line LEACHING LINE ❑ No. &.Length of lines Total length/size FILTER BED fl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Wail Foundation Property Line DISPOSAL PONDS ❑ ' 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 f 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 perfofmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• tion laws of California." The applicantIs s call-for all requir •Hsps ns. Complete swing on reverse side. , Signed Title: /i. 3 n/F_�2. _ ._ _ Date: OR DEPARTMENT USE ONLY Application Accepted by: C.�✓. 3�{ PP Y Date.�. .� Aras A Pit or Grout inspection by Date Final Inspection by Date 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 2009, STOCKTON, CA 95201 FEE If Y INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. a EH 13•Y4 114ty.1/A 51 EH 14.26 w.