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APPLICATION FOR .PERMIT SA N JOA@UI�RoT�PUBLIC A,TH DIV S ON SERVICES ENV PHONE (209)468-3420 1601 E. HAZELTON AVE• ' KION, CA 95201 P O BOA 2009, STOC ggP RES 1 YEAR FROM[ D i Tri licate) a (Complete in A for a p k and 1862 and the Rules and Regulations of San b made to SanancefJos4uin County ermit to construct and/or install the work herein described. This Application is here Y uin County Ordinance No. 549 l application is made iinHeoal�thiServiceah San Joao of Sine/Acreage Joaquin county + Job Address Phone Address L5F ` L! Owner's Nam 1 PhoneLicense No. li C__ r3 -_�- Well * LICTIQN ❑ Out of Service Address DESTR Well Contractor ❑ WELL REPLACEMENT ❑ Monitoring L7 NEW WELL ❑ OTHER ❑ TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ PRQP. LINE PUMP INSTALLATION ❑ DISPOSAL FLD•� -� SEWER LINES ------- ti PITSISUMPS DISTANCE TO NEAREST: SEPTIC TANK �--�-- 'OTHER WELL -- I FOUNDATION �r AGRICULTURE WELL ., PROBLRA CONSTRUCTION SPEClF1CATIONS ,. Dia. of Welt Casing INTENDED USE TYPE OF WELL pia. of Well Excavation Q Open Bottom ❑ Manteca Specifications-----�---- F7 Industrial 1 ❑ Tracy Type of Casing I Type of Grout FI Domestic/Private ❑ Gravel Ps k Depth of Grout $eal Public 1.1 Other n Delta I'1 Surface�5eal installed by '- I I Irrityauon Apptox' Depth 1 I Eastern State.Work Dane s t r H.P. Repair Work Done ❑ Type of Pump �--� SeSling Materil & Depth Weil Diameter �--�- g Well Destruction ❑ Filler Material & Depth J Depth tic system permitted if public sewer is I REPAIRIADDITION l I„ DESTRUCTION I i�available vritfiirt'200"feat.) TYPE OF SEPTIC WORK: NEW INSTALLATIO installation will serve: Residence Commercial — Other Number of living units: � = Number of bedrooms�---- Water table depth Character of soil to s depth of 3 feet: Capacify, No. Compartments SEPTIC TANK ❑ Type/Mfg _� Method of Disposal �i �----- PKG. TREATMENT PLT.❑ Property Line r Foundation �- Distance to nearest: Well • Total length.,!! LEACHING LINE No. &;Length of lines r Foundation _ - Property Line FILTER BED ❑ Distance to nearest: Well Number Size �- J SEEPAGE PITS X1 Depth+ Property Lins_�---' .. x SUMPS LI Distance to nearest: Well, Foundation t DiSPOSAL PONDS ❑ certify that I have prepared this application and that the work will be dans in accordance with San Joaquin county ordinances. state laws, and I hereby ce Y rtormanee of the work for which this permit is issued, l shall not rules and regulations of the San Joaquin County 1 certify that in the pe Home owner or licensed agent's signature calcifies the lol o workman's : " persons subject to workman's compensa employ any person in such manner as to become sunceecof the wok for which ethis permitlaws ssued, I shall employ pe is hiring or sub-contracting signature r P orma ` certifies the fallowing:"1 certify thatiln the pe / tion laws of California." + /4A/ /� L The applicant must call for all required inspections. Complete drawing on reverse side. Date: / - Title: R f Signed A F DEItATMENT.USE ONLY Lr� fA Area Date t - � 11kk l' Date r Application Accepted by Final Inspection by Date { Pit or Grout Inspection by Additional Comments: II uin County Public Health Applicant - Return all copies to: san Joh vironmental Health permit/Services k Services, En 1601 E. Razelton Ave., p 0 Box 2009, Stockton, CA 85201 PERMIT'NO. CK RECEIVED BY DATE FEE AMOUNT DUE AMOUNT RENtIT7fED' CASH O ' INFO "•`w.�' '� �r t � -�} 1 . l i 17.24 1Rill tl�f i 11 144e