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APPLICATION FOR PERMIT SAID JOAQUIN COUNTY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIYISIO01 P O BOX 2009, STOCKTON, CA p Cc' (209) 468—"4-734-7-0 ` Y R (Complete in Triplicate) This Application is hereby madeto San Joaquin County for a permitde . Application San to construct and/or install the work herein d application is mads in camr,llence vith San Joaquin County Ordinance No. 549 and 1862 and the Rules sad egu Joaquin County Public Health Services. 01 •D City Lot Size/Acreage job Address 5 ~�� Phone ' R�� Address Owner's Name Ljoq/ 0 1 License No. Q Phone r n � Address Out of Service Well ❑ 1 Contractor `� - WELL REPLACEMENT �] DESTRUCTION ❑__ Well y NEIN'INELt . OTHER Q Monitoring C7 I TYPE OF WE _IPUMP: _/ SYSTEM REPAIR ❑ f -pIjMIP INSTALLATION i2 -. f DISPOSAL FLD.— PROP. LINE �-------- DISTANCE TO NEAREST: SEPTIC TANKSEWER Lt N ES--�----- AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION �.--�— 1 INTENgEO USE TYLIE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing- pen Bottom ❑ Manteca Dia. of Well Excavation C1 Industrial Type of Casing "�' Specifications ❑ Gravel Pack Cl Tracy p' Type of Grout U Domestic/Private p Delta Depth of Grout Seal blitI'1 Other Surface 5ea1 Installed by lOation �.ApproK, Depth ❑ Eastern �. H.P.of Pump-7State Work Done � pair Work Done� U TYPa Se Ing Material i Depth t � Well Destruction ❑ Well Diameter Filler Material lr Depth t Depth permitted it public $ewer is An _ available within 200 feet:i= - � V TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION DESTRUGTIONCI lNo septic system it CommofCIS -- ' Other — Installation will senna:.= Rasidenca�.�.=� ._ Number of living units: Number of bedrooms f Water table depth Character of toil to a depth of 3 feet: I Capacity— No• Compartments G SEPTIC TANK 0 Type/Mfg � 1 Method of Disposal PKG. TREATMENT PLT,❑ Foundation Properly Lina Distance to nearest: Well Total length/size LEACHING LINE Cl No. & Length of lines Propeny Line - FILTER BED Cl Distance to nearest: Well Foundation 1 Sire i Number SEEPAGE PITS 11 Depth Property Line��- SUMPS Ll Distante to nearest: Well Foundation ' DISPOSAL PONDS ❑ I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, an I rulas and regulations of the Sen Joaquin County ' Homs owner or licensed agent's signature canities the following: "I certify that in the performance at the work for which this permit is issued, V shall not 1 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature employ the person in u certify that s the performance of the work for whicht this permit is issued, I shall employ persons subject to workman's compensa- followi i tion laws of California." The applicant ')us 4 for all r red inspeptions. Co late drawing on re side. l o Date: kTitle: �r Signed 11i . i t R DEPARTMENT USE ONLY l Area - �c Application Accepted by:... ._ f Date A9 Pit or Grout apection b Date - Final Inspection by Additional Comments: Applicant - Return all copies to: UNTY PUBLIC HEALTH SERVICES ENvIRONMENTALJOAQUIN OHEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P o BOX 2009, STOCKTON, CA 95201 GK RECEIVED BY DATE PERMI7'NO. t;NFO AMOUNT DUE AMOUNT REMITTED CASH f � � ." j � Ir•�� . EH 17-2A IREV. EH,ale