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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 iI PER1dIT E%PIRES l Y FR M DATE ISSU (Complete in Triplicate) �I Application is hereby made to Ban 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. 51+9 and 1962 and the Rules and Regulations of San Joaquin County Public Health Services. Lot Size/Acreage G � city " .lob Address Phone Address Address Owner's Name �.' _ nqa— ho = .7 ------- - - - r-�iiress "" `_ -License-No � " Contractor TYPE OF WELL/PUMP: r NEW WELL WELL REPLAGEMi NT ❑ DESTRUCTION Ll Out of Service Well n OTHER ❑ Monitoring Well PUMP INSTALLATION *Z, SYSTEM REPAIR.❑ i _-'� " � i DISPOSAL FLD. PROP. LINEam:5 DISTANCE TO NEAREST: SEPTIC TANK — SEWER �. OTHER WELL PITS/SUMPS AGRICULTURE r FOUNDATION AG ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO IS r _ r-yt Dia. of Well Casing Cl Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Jai Specifications omasticlPrivata\•.❑ Gravel Pack C3 Tracy Type of Casing- ie asing- I� N� ' li fl pelta Depth of Grout Seat Tyne o rout I'I Public r1 Other ¢:'i h„ I I Irrigation Approx. Depth, t { Eastern urface Ssai insulted _, t_: H P 1 State Work Done Repair Work Done" U Type of Pump sealing ; W C , Material els Depth" Well Destruction ❑ Well Diameter w i . Depth Tiller Miterial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I �S7RUCTION I aNa'I'blet�wthin-20stem 01eelged it public sewer is Installation will serve: Residence Commercial— Other Nti bar of living units: Number of bedrooms Watiii table depth } Character of$oil to a depth of 3 feet: SEPTIC TANK. f0 Type/Mfg !` Capacity _ No.. Compartments .... ..x r. PKG. TREATMENT PLT. C1 �` Method of Disposal � Distance"to nearest: Well Foundation ,Property Line ! LEACHING LINE ❑ No. 6 Length of lines Total length/size fIL'TER BED ❑ Distanc4 10 nearest: Wall Foundation Property Line SEEPAGE PITS 1 l Depth ! Size Number - SUMPS LI Distance.to nearest: Well Foundation Property Line j DISPOSAL PONDS ❑ 1 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 to workman's compensation laws of California."Contractor's hiring or sub-contracting signature empty any person in such manner as to become subject cartifiea the following: "1 certify that in the performance of the work for which this permit is issued, I shell employ parsons subject to workman's compensa• tion laws of California." r The applicant at call to 1 requir 11,111111 aclions. Complete drawing on reverse side. Sip AA Title: Date: i OFf-DEPARTMENT USE ONLY Application Accepted by l Date Area ! Final Inspection by f' Date Pit or rota nspaction by� Date n Additional Comments: I iApplicant -'Return all copies to. San Joaquin County Public Health Services r Environmental Health Permit/Servicer§ 445 N San Joaquin, P 0 Box.2009, Stkn, CA 95201 3 FEE ;CASH K- RECEIVED SY DATE PERMIT"N0.`I�F„„ AMOUNT DUE m� AliA011Nt iiEMITTED— ^�EH 13.24 1REV.t/N 5!Vci J+V/ �� .I'� r EN 14.28 _ �'3 �" _/ 4