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F APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN. JOAQUIN, PHONE (209)468-3420 yrs'' P 0 BOX 20092 STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR 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 application is Elide in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job AddressI City Lot $ize/Acreage Owner's Name Address - Phone v.� Contrac 21 Addres� �z� License N� Phone r'A / TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION_ 1� SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES 1A DISPOSAL FLD. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Die, of Well Excavation Dia. of Well Casing 54-usa-walit/private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i'I Public 1"1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation /`'�Appfox.'Depth 11 Eastern Surface Saul Installed by Repair Work Done Uir Type of Pump:^ H.P. t State Work Done Well Destruction ' ❑ Well Diameter -A,,.;'ming Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION'(.)-DESTRUCTION E I (No septic system permitted if public sewer is available within 200 feet-1 \ Installation will serve: Residence_ Commercial Other ' ~" . , Number of living units: Number of bedrooms Character of soN to a+depth of 3 feet: Water tabPAPI V` SEPTIC TANK ❑ Type/Mfg Capacity ' No. REMIVED PKG, TREATMENT PLT.Ll Method o I Distance'to nearest: Well Foundation' Property Line 91993 chri tr)A6lI1NQ0LI!% LEACHING LINE 0 No. 8 Length of lines Total tength/size Et JRUC HEALTH SE- FILTER BED ❑ Distance'to-neare'st: Well oundation WENTAL HLAL I n SEEPAGE PITS I-I ,Depth --- Size Number SUMPS ' .L•1 -Distance to nearest: Well Foundation c fAroperty,Line DISPOSAL PONDS 1!' 1 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 certifies the following':."I ctirtify;that in the;performance of the wont for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's cornpensatioh'"of California."Contractor's hiring or sub-contracting signature certifies the fallowing: "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." p The applicant r sit required.' spe.ctions. Complete drawing on eras side. i �--7_ Sig rmad Title: �� _ Date4 } FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by t^ Date -16 '97J Additional Comments: Applicant -Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 H San Joaquin, P z 2009, Stkn, CA 95201 __1 FEE AfAAU�JNT DUE AMOUNT REMITTED': „ CA' ECEIV BY D TE PERMIT'NO. . ENI 3,24{REV. /ti 5) / �y EH 14.70 C/ f