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i� APPLICATION FOR PERMIT � 0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES (� ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-r3447 pEgMIT EXPIBB§ 1, YEAR rR-99 DATE..ISSUED (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 coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San J�f County Public Health Services. �/1 Job Address .� / F� = 40 City Lot Size/Acreage ,f r4r��T -_ Owner's Name . C U�� F/ - dress &2067 _JCAIP—�7��-`�-- Phone -3 Contractor Address =-- icense Noz=.il _Phone TYPE OF WELOPUMP: NEW WELL'S WELL WfLACEMENT F-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _BOTHER ❑ Monitoring Well � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLprJ� (.1PROP. LINE ' FOUNDATION "`�� AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,"omestic/Private -Gravel Pack ❑ Tracy Type.of C#s.n-g Ste•�A Specifications`r - t M Public Cl Other O Delta Depth of Grout Seal � �^� �Type of GroutS E- Irrigation _QJ':j0pprox. Depth JI-Easlom 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 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION L3 RE PAIR I ADDITIO114"M DESTRUCTION Cl (No septic system permitted if public sewer is available within 200 feet) 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 ❑ TypolMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest. Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Total length/sire FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size Number SUMPS LI Distance to nearest; Well Foundation Property Lino DISPOSAL PONDS ❑ 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 eanifies the following: "I mify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa• tion laws of California.' The appy t all r e quired insPection&, Complete drawingon a rise si - Signed Title: Date: F DEPARTMENT USE ONLY + Application Accepted by Date *�� Area Pit or Grout nspection by Date Final Inspection by Date Additional Comments: - Applicant - Return L1.1 copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEEOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH SINN I-kA (�r, . EM 13-74 KIEV.iixSl ,aa 9t 11 -90 EH 11.26