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APPLICATION FOR PERMIT ti 9. 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N. SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 li I . P T E WIRES 1 YEAR FROM DATE ISSUED } (Complete in Triplicate) Application is hereby made to Ban 'Joaquin County for a permit to construct end/or install the cork herein described. This application is made in cowlience Frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f err ,� � t 3 Ac° f City �'v fe.4 Lot Size/Acreage Job Address Owner's Name �,Q1��_j �? i,/ rt1 cS,S�!� Address 7e 1 toe ..., — Phone � ! Contractor IR "nJ i S � AddressA� ,tAIA2 1 License No. H39� Phone .9�0-3 YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out or Service Well 0 Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO5AL FLD. PROP. LINE " ' ; s PITS/SUMPS FOUNDATION AGRICULTURE WELL. OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �] i Dia. of Well Casing L1 Industrial ❑ Open Bottom ,❑ Manteca, } Die.of Well Excavation �• Ll Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing- Specification VI Public 1"1 Other ' "'"" -1'Deltas""""""Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal 1rii;talled by 4 ! H.P. + State Work Done, Repair Work Done L7 Type of Pump i Sealing Material A Depth E Well Destruction ❑ Well Diameter s Depth f biller Material 4 Depth TYPE OF SEP.:TIC.WORK; NEW INSTALLATION l I REPAIRIADDITION 14 DES TRUCTI vai,sept able wit in system jeep ted it public sewer is 1 r I Installation will serve: Residence Commercial_ Other Number of living units: Number ofl bedrooms �n L ' Character of sols to a depth of 3 feat:' _. -- .•: -- "` Water table depth SEPTIC TANK. ❑ Type/Mfg` Capacity No. Compartments PKG. TREATMENT PLT:❑ Method of Disposal Distance V) nearest: Well Foundation . Property Line jt ' LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth } Size Number SUMPS ,Ll 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, stats 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 parformance of the work for which this permit is issued, I shall not employ any person in such mtrirner as to become subject to workman's compensation laws of California." Contractor's hiring OF 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 compansa- tion laws of California." The applicant M or all r ired 'inspections. Complete drawing on reverse side. " Date: ^� �� Title: { EP RRTMENT USE ONLY Application Accepted by r Dots Area �L + ! Pit or Grout Inspection by 4 Date Final Inspection b pate .S Additional Comments: t f Applicant - Return all copies to: Ban Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMI7'NO. INFO CASH • EN 13•t41REV.rinai 7 � ( 0� ®© J �`a 6 EH 1�•Ie