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~ APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOF 2009, STOCKTON, CA 95201 13 . (209) 468-3447 i (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 made in cottipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Reedfixlons of San Joaquin County Public Health Services. _ Job Address City ALL Lot Site/Acreage %O \- Address - t Phono2cff � Owner's Name • - i Contlactor.;ti \ � L-�-k�C-t�{Addr WlL- ense-No.3-7G- 7 Phone C� TYPE OF WELL/PUMP. NEW WELL WELL. REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 0 Monitoring Well L3 ' DISTANCE TO NEAREST: SEPTIC TANK �'�" SEWER LINESDISPOSAL FLD,L�- PROP. LINE �Cod FOUNDATION `�� AGRICULTURE WELL OTHER WELL PITS/SUMPS t:.1D INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICA_JON of Well Casin /0 Ll Industrial Open Bottom ❑ Manteca Dia. of Well Exceva�llon� Dia 1Xporriestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications fir, M Public V1'Oiher © Delta Depth of Grout Seal Typp of Grout "tnk "X'Irrigalion .Approx. Depth C) Eastern Surf, Seal Installed by t� Repair Work Done U Tyrpe of PumpSLu1A�btt.P, � State Work Done t Well Destruction ❑ Well Diameter Sealing Material k depth �•1 Depth Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION G INo septic system p�armittsd if public sewer is -5 available within 200 featJ Installation will serve,- Residence — Commercial_ Other Number of living units, t Number of bedrooms Character of soil to a depth.of 3 feet: Water table dipth SEPTIC TANK. 0 VType/Mfg Capacity No. Compartments PKG, TREATMENT'PLT,-C1 - ;� Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ �No. & Length of lines Total length/size 3 , -FILTER-BED n ,'Distance to nearest: Well Foundation Property Line t SEEPAGE PITS 11 %Depth Size Number SUMPS L1 :Distance to nearest: Well Foundation Property Line DISPOSAL. PONDS ❑ 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 t _ r 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 iu0h manner as to become subject to workman's compensai+on 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." ° The applicant call fly all.required inspections. Complete drawing on reverse side! -9-A Signed X l Title d = C-� Dater DEPARTMENT USE'ONLY Application Accepted by Date ��- r- + Area Z_ w. Pit or uI Inspection by Data Final tnspection'by Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES s ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 f FEE AMOUNT DUE A OUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH _ _ _ . R- Z L 1,.22441REY.I/x51 -S.^� i�� !, fi0 // 2 4A ✓;