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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMMTAL HEALTH DIVISION 445 N SAN JOAQUIN, .PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED µ (Complete in Triplicate) Application is hereby made to San Joaquin County ifor a permit to construct and/or install the work herein described. This application is made in compliance vith.San Joaquin.County Ordinance Ho. 544 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 10:5210 IV, (2l City 57re/1-,717AJLot Size/Acreage Owner's Name -D A V F_ 'C L G 141 Address 9Z&?Z1r _ Phone Cont raclor SCD�D /r/rlo - Address .0 .?i7D�`L l��i�T License No, f�`2: 6 Phone 'AS-39'71 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR L OTHER p Monitoring Well ❑ DISTANCE TO'NEAREST;=SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel.-CCasing [7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specilications'' i•1 Public n Other F1 Delta Depth of Grout Seal _,Type of Grout \ I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material i Depth " r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I_(No septic system permitted if public sower is. available;wiihin 200 feet.) i Installation will serve: Residence '� Commercial— Other Fp9 ,•P®ol_ j/005E (G/P 6A Ua)Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: /?—1_4 J/ Water table depth SEPTIC TANK O Type/Mfg PV11 Capacity 1-2�o C? No. Compartments -2— PKG. PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well 6YA Foundation 7 Property Line r UPJ r LEACHING LINE . No. 8 Length of lines /w / Total length/sire / FILTER BED CI Distance to nearest: Well.--Al - Foundation _ '3d r Property Line I-5: SEEPAGE PITS rf Depth e Size l p Number SUMPS LI Distance to nearest: '. W� _ Foundation .a Property Line DISPOSAL PONDS ❑ E) ey I hereby certify that I have prepared this application and_that the work will be done in accordance with San Joaquin county ordinances, statelaws• 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."Contractor's hiring or sub-contracting signature certifies the following: "I eartify that in the performs6ffe of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: / ,„`� FOR DEPARTMENT USE ONLY i Application Accepted byDate Areal' Ph or Grout In r d spectbn by �' Date Final inspection by o Date I Additional Comments: + Applicant - Return all copies to: San Joaquin County Public Health Services i Environmental Health Permit/Services �r 445 N San Joaquin, P O Box.2008, Stkn, CA 95201 F !EENIF AMOUNT DUE AMOUNT REMITTED 1"4K CEIVED BY DA E PERMIT DA . EISM24(REV.riesr L EH 440 1 !!