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i a APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209 Y 468-3447 x j .PEMIT EXE11195 I XBAR PROM DATE ISSUIM (Complete in Triplicate) Application to hereby made to San',:Joaquin County for a permit to construct and/or install the vork herein described. This t application is made in compliancejvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servi'cee. Job Address City Lot Size/Acreage Owner's Name $ ► 6_drf009 )II-S- Address - Phone Contractor in, 4W)A0 Address A&Z oevix License NPhone TYPE OF WELL/PUMP: NEN WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well Q PUMP INSTALLATION`- SYSTEM REPAIR ❑ ' t OTHER ❑ Monitoring well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER Lli ES'- D1SPO5AL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ..� INTENDED USE TYPE OF WELL A6bLEMV AREA,- CONSTRUCTiION SPECIFICATIONS w n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing VQlam-40CIPrivale ❑ Gravel Pack. ❑ Tracy Type of Casing i Specifications f13 Public cher p Delia Depth of Grout Seal Type of Grout 0 lnipalion Approx. Depth ❑ Eastern urface 4al Installed by 1 Repair Work Done Type of Pump,--IUA H.P. _ - - State Work Done Well Destruction © Well Diameter LZ / ming Material i Depth Depth Filler Material Z Depth TYPE OF SEPTIC WORK: NEW INSTALLATION JO REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence..r�"Commercial— Other Number of living units: Number of bedrooms t Character of *oil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to;nearest: Well Foundation Property Line r v] LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 1-1 Distance tolnearest: Well Foundation Property Line SEEPAGE PITS I I _ Depth Size Number SUMPS LI Distance toi:nearesi: Well Foundation Property Line DISPOSAL PONDS ❑" !. 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 ' 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 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 law*of California." 1 �" The applicant t call _ uired ins1lopions. Complete drawing o <.17 Signed Title: Date: FOR DEPARTMENT USE ONLY ~" - Application Acc by Dale r �Area" Pit or Grout Inspection by _ Date Final Inspection by - data Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ,.a '�,/ "ENVIRONMENTAL:HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 IEEE AMOUNT DUE AMOUNT REMITTED CASH K 11 RECEIVED BY DATE PERMIT"NO. NFOa EH 13.24(REV.,ix'5I m r� t�� EH 11•I6 - ,_