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�& li 4 �) APPLICATION FOR PERI[I T i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I� ENVIRONMENTALHEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 F I P O BOX 2009, STOCKTON, CA 95201 .I . PERMIT-EXPIRES-1 YEAR FROM DATE ISSUED �I (Complete in Triplicate) Application is hereby am e.to San Joaquin County for a permit to construct and/or install the York herein described. This application is made in ceelpliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 3 Job Address 32 t:�L.UTi�I 12D City FA1 Got Size/Acreage Owner's Name IIf Addresses 9S23e) Phone ` ,, �,t 11 4t�cJ mo-v T / COnttactarw[J Address K� License No.•' 1 �`-� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION fi— SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS p i N INTENDED USE TYPE OF WELL PROBLEM AREA? CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing (4-Goomest_ic/Private. Cl Gravel Pack 1 ❑ Tracy Type of Casing Specifications f l'1 Public [:7 Other . r fl Delta i Depth of Grout Seal Type of Grout I I litigation _I .Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 'L] Type of Pump > H.P. Statq Work pone Y �� Well Destruction 0 Wall Diameter _ Sealing Material i Depth Depth Filler Naterial i Depth , LA TYPE OF SEPTIC WORK: NEW INSTALLATION.[ i REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is a available within 200 feet.1 Installation will serve: Residence_ Commercial Other' y Number of living units: Number of bedrooms Character of*oil to a depth,of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg 5 Capacity No. Compartments PKG. TREATMENT PLT.❑' .��' _r'_f_ __.,_ _ ._ R Method of Disposal f Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED 0 Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well ' -Foundation Property Line DISPOSAL-PONDS—0-W C I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and rulas and regulations of the San Joaquin County i 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature t certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." I� t The applicant must call for all required inspections. omplete drawing on r verse Signed Title 12 Date: € I O EPARTMEN SE ONLY I Application Accepted by —_ Date ` Area ' Pit or Grout Impaction by Date. Final Inspection by � Data IrkAdditional Comments: Applicant - Return all copies to: San Joaquin County Public'Health Services Environmental Health Permit/Services iE 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATE PERMIT'NO. INFO I /� • Em 13-24(REV,1/95) '�O� L./(J-� D � 3 �I% EH 14.38 !!