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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 9520 . (209) 468-3447 yxgul=_ AM Y R (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 made in crsspliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name Q'1t6dress Phoria 4� ConitaclorL;��,ddress §564 — __ Q�+ 'rLicense No. Ph on ROO j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPL EMENT 171DESTRUCTION ❑ Out of Service Well ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 17,71 Industrial ❑ Open Bottom ❑ !Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications - M Public I11 Other ❑ Delta Depth of Grout Seal Type of Grout CJ Irrigation ____.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P, State Work Done Well Destruction © Well Diameter Sealing !Material i Depth Depth Filler Material i Depth \ TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIRlADDITIO DESTRUCTION hi (No septic system permitted if public sewer is available within 200 feet) 1 Installation will serve: Residence,„ Commercisil Other + Number of living unit e:� Number of bedCharacter of roo )) SEPTIC TANK aorl to a ptid th of 3 teat: w Water table depth N ❑ Type/Mfg '` Capacity_,,.2 ,�....,,,J No. Compartments PKG. TREATMENT PLT. Q """` ""` Method of Disposal Distance to nearest: Well Foundation Property Line 42,0 LEACHING LINE ❑ No. 8 Length of lines Tota length/size FILTER BED C. Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Sire 46rl Number SUMPS Li Distance to nearest: Well Foundation I Property Line ' 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, 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 subcontracting signature certifies the following: "I comity 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 ap quired in",c n mplete drawing on reverse side, o Signed X Title: Date: -4?Z ]A a N FOR DEPARTMENT USE ONLY A iication Accepted by Date_ ` Area Pit r Grout Inspection by Date Final Inspection by Date •Z�•�Z Additional Comments: l Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC H ALTH SERVICES V � -1 7-epy1 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES b, aLt-� ll 445 NAN JOAQUIN, P O BOX 2408, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTEt7 CK RECEIVED BY DATE CASH PEAMiT'N0. 11q,1q, It-, ` 1