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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-344-7-- 3,J-Z_0 . YEAR FROM DATE--ISSUM (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.® I Job Address 9v g1 2QI e City Lot Size/Acreage ] (� L, Owner's Name Address I O L- 1we 7/d Phone Contractor Address 4 S�w eu � License No. l Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION C) Out of Service Well ❑ PUMP INSTALLATION W1, 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 _ Y fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing Xbomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f M Public Il Other ❑ Delta Depth of Grout Seal Type of Grout M trfigation _,Approx. Dep D Eastern Surface Seal Installed by Repair Work Dona L7 Type of Pump , H.P. Stats Work Done Well Destruction ❑ Well Diameterl�t Sealing Ffa ria) 4 Depth Depth „S _ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIAODITION 0 DESTRUCTION 0 (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 ❑• Type/Mfg. Capacity No. Compartments PKG, TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property U60 - I i LEACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line t SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to neeresu Well Foundation Property Line , DISPOSAL PONDS. w__❑— 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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any persorrin such manner as to become subject to workman's compensation laws of Celilornia." Contractor's hiring or subcontracting signature certifies the following: "I certify 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." 4 The applicam'm call for all r fired ' spections. Complete drawing on reverse side. Signed Title: Date: lU FOR DEPARTMENT USE ONLY ] I Application Accepted by Z Date Amp ' Pit or Grout Inspection byDate Final Inspection by Date a Additional Comments: Applicant - Return all copies SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIV 8t' DATE INFO PERMIT'N0. EH 1314 IREV.I/n 51 //t ,`-.: / EH^,4.28