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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 PE_MIT EXPIRES 1 YEAR ROId DATE 1S$UD s j (Complete in Triplicate) Appllca�Ion is hereby made•to S JoaqulnuCJout 0A1for 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. C� Job Address 195 040 08 - - City Lot Size/Acreage ON= gSa3lo Phone Owner's Name Address �1 j� Contractor Address m License No. s��Phone`r 610- Contractor OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHEP ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK 46C3f SEWER LINES A50 DISPOSAL FL.+5 POP. LINE ± FOUNDATION 56 AGRICULTURE WELL tS-0 OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI N Geoff i.50'(n9s C3 y M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public CI Other O Delta Depth of Grout Seal Type of Gro t Mi Irrigation —Approx. Depth 0 Eastern Surface Seal Installed by /6,00 Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 1: Depth Depth Filler Material Z Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION -1 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other /J 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 laws of C la." The applic t mus call for ell oq ed i060. o . Complete drawing on reverse side. '712 ' Signed X Title: _--� /L, r - Date: -7Z F DEPARTMENT USE ONLY f, l Date u 2 Ar l Application Accepted by / Pit or Grout Inspection by Date Final Inspection by,,.-, Pete% im Additional Comments: U WX-afC/ - A"Applicant - Return copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERV CES �� '��f ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CCK ECEIVED BV OATE I PERMIT NO. INFO 1t1r5R . EH 13.24I11EV.rin5r EH i4,2a 6