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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 r � _YIs"AR FROM 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 I application is rade in coa�liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r Job Address City Lot Size/Acreage Owner's Name - 1 � /Rnress�� 8'¢g ,� Contractor DD S Address 4-41' License No.�Phone�J I TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ i 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,S:PECIFiCATIONS -� C"1 Industrial O Open Bottom ❑ Manteca Dia. of Well EYcavition Dia. of Well Casing U Domestic/Private ❑.GfAvel P_sck,.,-_ O Tracy�.�,,,. TVPO-of-Casing— -- .Specifications ❑ Public ill Other ❑ Delta Depth of Grout Seal Type of Grout Cl Imom(ion q �.�pprox, Depth ❑ Eastern Surface Seal Installed by Repair Work Donex_U Type of pump Ar H.P. State Work Done Z l Well Destruction ' Well'Diameter Sealing Material i Depth . , . ,. r _w y� , DeRth ` - — Fiiler Material i Depth TYPE OF SEPTIC WORK:'_,NEW INSTALf..ATI,ON❑ REPAIR/ADDITION Li DESTRUCTION G INo sepnc system permitted if ptrblic sewer is available within 200 feet.) I Installation will serve: Residence— Commercial— Other'o Number of living' units: Number of bedrooms 11 Character of soil to a depth of 3 f s'`"`�' `-' ,1 SEPTIC TANKType/Mfg Water table depth PKG. TREATMENT PLT, Capacity No. Compartments �1 :. - ';� � • v, ^��"�- Method of Disposal f ✓ Distance to nearest: WellFoundation Pro _ , .� � --�, �-a4.-..,,-�,, _ •--�.� -�• perN Line LEACHING 1.4. ',,�❑ No, g Length of lines ' Total length/size FILTER BEDS [I Distance to nearest: Well Foundation. • Property Eine SEEPAGE PITS 11 Depth 'Sire . Number I SUMPS LI Distance tonearest: .. Well Foundation DISPOSAL PONDS ❑ f Property Lina !`her$by certify that I have prepared this application and.that the work will be done in accordance with San Joaquin county ordinances, state laws, and /rulss and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that inethe performance of the work for which this permit is issued, I shall not smploy any person in such manner as to become subiect to workman's compensation laws of California." Contractor's hiring or sub contracting signature ^°r CeRifies the following; "l Certify that in the performance of the work far which this permit is issued, f shall employ persons subject to workman's compensa- . tion laws Of California." The applics m c t r r coons. Complete drawing on reverse itis- Signal Title: Date: R DEPARTMENT USE ONLY Application Accepted byQ Date l Area Pit or Grout Inspection by DateS' Fina! Inspection b Date r Additional Comments: i Applicant - Return all copies to 1`SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES R t ^ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <�T445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEfVED8 Y DATE PERM17'NO. . EM 17.24(REV.I?M 51Lu 0C>