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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 A (209) 468-3447 f Y R � p �QZ` 191 0� � J. �p�e in Triplicate) A licotion is hereby mad to San oaquin County fo permit to construct and/or install the work herein described. This application is made in cozpliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. . &,v-Ltka �!City � -Lot Site/Acreage Job Address _&WA2ZHIM 92"11 ' !a3 �b$,SS L.nl,5acTj � /07— Owner's otiOwner's Name �, 17LtJ L Tb j _-- Address _C166Ei" &LV _ d� Phone °'^ ZS�S JCCZZfj Phan 8-13 S Contraclar e Ammem License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of service well D. PUMP INSTALLATION D SYSTEM REPAIR C7 OTHER Monitoring Well C7 � 3 IEsr j;aRcN'Gg 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 ff- f-7 Industrial D Open Bottom ❑ Manteca Dis. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack n Tracy Type of Caking Specifications M Public Cl Other D Delta Depth of Y J I —Z� Type of Grout NNCJ Irfigation ____,Approx. Depth C) Eastern Surface Sea] installed by G i Repair Work Done U Type of Pump H.P. State Work Donee �-U�[ a= � Sealing Material & Depth %A. LE WG" Wall Destruction D Wall Diameter t`+ Depth Filler Material & Depth W TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION G INo septic system permitted if public sewer is available within 200 feet.l 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. D Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/sire FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS U Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D 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 Sen Joaquin County Home owner or licensed agent's signature comifies 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 certifies the following: "l 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." The applicant u I all for II required irppections. Complete drawing on re aid Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by /!% Date rIrArea Pk or Grout Inspection by / ate Final Inspection by Dat Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, ST=TOM, CA 95201 FEE AMOUNT DUE AMOUNT REMIT"tEOK RECEIVED BY DATE PERMIT NO. INFO CASH . EH 13.24 IREV.r/"W �-� Z:Z =' EH