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[/ APPL A,T I ON FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` L ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 +i_ -YEAR_ PROA DA, JIM= (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This . Application Is made in ct�liance with San Joaquin County Ordinance No. 549 and 1862 and t e Rules and Regulations of San Joaquin County Public Health Services. ��#78 Job Address City Size/Acreage k Owner's Name �[/ ddress ' ` �&, T� L,.-..�» �"..�...r�--�.,.....�._,..,��-......�.---,..- ._-. -•-—,_-.. , ..:�4..�:4 a�-� hone Contractor ' Address License No, Phone TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT n DESTRUCTIOtot Service Kell ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ ;OTHER ❑, .f Monitoring Well LI " i' DISTANCE TO NEAREST: 'SEPTIC TANK SEWER LINES DISPOSAL FLD. PAQP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL /PITS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' n Industrial ❑ Open Bottom O Manteca Dia. of Weil Excavation Dia.,of Well Casingr U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing }Specifications a L7 Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout cl Irrigation Approx. Depth ❑ Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work D� _ no • ��C1 � Wall Destruction „DW Well Diameter �- Sealing Material i Depth /dip Depth Filler Material i Depth TYPE OF SEPTIC WORK; NEW INST AIR/ADDITION LZ DESTRUCTION M INo septic system permitted if public sewer t available within 200 feel.) y -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 O Type/Mfg Capacity_ No, Compartments mm PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line r . LEACHING LINE ❑ No. 8 Length of lines Total length/size + FILTER BED + n Distance to nearest: Well foundation Property Line Li SEEPAGE PITS 11 Depth Site Number r r r SUMPS , Cl Distance to nearest; Well Foundation Property Line 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, at rules and regulations of the San Joaquin County ate laws, and. Home owner or licensed agent's signature certifies the following: I•certif that in the a �.s employ an '� Y performance of the work for which this permit is issued, I shall not p y y person in such manner as to become subject to workman's compensation laws of California." Contractor's hiringor sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subiect to workman's compensa- tion laws of California." - The spplican �'"�G uir Complete drawing on reverse l Signed ide: - /z ' Data: M!=.Dats- Y " A' Application Accepted by _ L 1 ` 1 Area Pit or Grout Inspection by _ Final Inspection by Date Additional Comments Applicant - Return all copies toil SAN JOAQUIN COUNTY PUBLIC HEALTH-SERVICES J ENVIRONMENTAL HEALTH-DIVI8ION PERMIT/SERVICES 445 N-SAN"JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUfvT DVE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERfNI7'NO. . tk 11-21(REV.tinSi r� �— fM