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t APPLICATION FOR PERMIT � pv SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES : ff ENVIRONMENTAL HEALTH DIVISION � � P O BOX 2009, STOCKTON, CA 95201 `• MAY �n (209) 468--3447 r PMIT (Complete I XEinAR -PROM DA }E ISSUED A�RMjr�SEf?4, HF L T� Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This 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 CQ iSt City Lot Size/Acreage'- _/J Owner's Name ,_, � Address =43La!6=R - Phoney Contractor;�� -5� Address &",064&4__ License No. p f.6�` Phone — S TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT C] DESTRUCTION C3 Out of Service well ❑ PUMP INSTALLATION � SYSTEM REPAIR � OTHER 0 Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE: FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t Cl Ind i I E-) OpenBottom © Manteca Dia. of Well Excavation Dia. of Well Casing f omestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications L) Public C7 Other ❑ Delta .Depth of Grout Seat Type of Grout M Irrigation _/_- .App(ox. Depth ❑ Eastern Surface Seal Installed by Repair Work Done a Type of Pump � H.P. ��'�� - State Work Done Well Destruction 0 Well Diameter Sealing Material &,•Depth f Depth Filler Material h Depth 1 TYPE OF SEPTIC WORK: NEWINSTALLATION ID REPAIWADOITION M DESTRUCTION G INo septic system permitted if public sewer is available within 200 feet.) « -installation will serve: Residence— Commercial-= Other'. �t y Number of living units: `L=-Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Lengefi of lines f - _ Total length/size FILTER BED I:I Distance to nearest: Well Foundation Property Line - r SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ t 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 1, ' t Home owner or licensed agent's signature certifies the following: "I corny 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 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 Iowa of California." The applicant must a (or all required inspections, Complete drawing on rev srde: '/ J Signed X Tide: �-- _ _ Date: C "�a FOR DEPARTMENT USEONLY Application Accepted by _z�eData Area 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 445 N SAN JOAQUIN, P 0 SOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT AEMITTED. CCK 9 RECEIVED 9y DATE PERMII'NO, 4 f�