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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--3447 PERMIT MIR95 I_-. k'R M DATE I_§SUED (Complete in Triplicate) Application Se hereby mode to Son Joaquin County for a permit to construct and/or install the work herein described. This I 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. * Job Address /vE P, D City Z=:: 1Z), Al,Lot Site/Acreage Owner's Noma 61114 W Address - -It.1. /" l),5ZAJ Phone a � Contractor F4Q YD- E Address 7 Al. AdE License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well U A� PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER ❑ Monitoring Well U DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ' 'PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM,AREA ' CONSTRUCTION SPECIFICATIONS s . 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 'L Dia, of Well Casing L Domestic/Private Cl Gravel Pack` C3 Tracy Type of Casing Specifications M Public �""`�'1.1 Other " " © Delta . Depth of Grout Seal Type of Grout z MI tfri0ation .._-_..Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H,P. State Work Done Well Destruction © Well Diameter Sealing Material i Depth vi Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION L1 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ZCommercial— Other Number of living units: __L Number of bedrooms Character of soil to a depth of_3 feet: L '" _ W fa t�able depth SEPTIC TANK. O Type/Mfg G�- YV W_ Capacity ZC�U No."Compartments PKG. TREATMENT PLT. 0 —Method of Disposal w Distance to nearest: Well /� 'h Foundation 7W _ Property Line r^' r LEACHING LINE No. 6 Length of lines Total length/size _ / FILTER BED n Distance to nearest: Well�1�lyf Foundation _ 7-O/ --- Property Lina SEEPAGE PITSI D6pth",..yS.�= $ire� _ .r Number SUMPS 'da,: Distance to nearest: Well Foundation Property Line �Q DISPOSAL PONDS O t hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not imploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• tion laws of California." 4. The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: -5- F DEPARTfMENT USE ONLY Application Accepted by ADate _aZ_ Area I Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: — Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES r 445 H SAH JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE I AMOUNT DUE AMOUNT REMITTED CK 1-7 CASH RECEIVED BY DATE PERMIT NO, INFO . EH 12-24 1REV.I/A$) LJtl L F 22 - r EH 11.26