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_ f APPLI=CATION FOR PERMIT - SAN JOAQUIN COUNTYgPUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH j r]_ Q /�3 445 N SAN JQAQIIIN, PHONE 72g— P 0� _- T-"f O BOX 2009, STOCKTON5201 PERMIT EXPIRES 1 YE FROML;D'1LPE#1S(Complete in Tripli _ fApplication is hereby made to San Joaquin County for a permit to construct % tall t1t�o�herti cCescrib is application ie made in compliance with San Joaquin County Ordinance No. 5Le n Joaquin County Public Health Services. / Job Address 7 City vt, Lot Size/Acreage Owner's Name �� Or) 4dress' dt? - Phone Contractor c_C/ Address 6 �r �/� License No Q Pho n04�9.5-C--- TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Nel1 ❑ PUMP INSTALLATION O SYSTEM REPAIR rd' OTHER ❑ Monitoring Well ❑ J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing + �.4pomesiic/Private ❑ Gravel Pack Q Tracy Type of Casing Specifications i l'1 Public Cl Other n Delta Depth of Grout Seat Type of Grout ! Irrigation �Approx. Dep I Eastern Surface Seal Installedd-by Repair Work Done )6 Type of Pump H.P. -.__!'�— State Work Done G , Well Destruction ❑ Well Diameter Sealing ail terial i Depth i Depth Fil-ler i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) i 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 w.,..,; Distance to nearest: Well Foundation Property Line _--ter-. LEACHING LINE Ll No. & Length of lines -Total length/size FILTER BED ❑ Distance to nearest: ' Wall * Fou+idation y^ T �� Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 1ha`t I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 'f rules and regulations"of the San Joaquin County Horne 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 subcontracting 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 lawn of Cali The appy t mus II fpr NI requir inspections. Complete drawing on reverse Signed Title: Y Date: FOR DEPARTMENT USE ONLY X Application Accepted by Date PIJZ Area l ` Pit or Grout Inspection by Date Final Inspection by Date Additional Comments:. Applicant - Return all copies to San Joaquin County Public •Health Services I� �Environmental,Health Permit/Services j 44519 San Joaquin, P O Hoxw2009, Stkn, CA 95201 I iNFO AMOUNT DUE AMOUNT REMITTED V00 d= GASH RECEIVED BY DATE' PERMIT'NO. I . EH IATI(REV.IiKSJ / l / Z G i1`/t7 EN 1 4•2: ..JJ