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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 YEAR rR-OM DATE LI-LM (Complete in Triplicate) Application is hereby rMe.to San Joaquin County for 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 d the.Rul en "tions of San Joaquin County Public Health Servi e. ��. dd>t'1� .. 0....i S+et Lot Size/Acre Job Address age Owner's Name dtA du>>��! Address Phone A � License No, Phone dres ��71 G 't S Contractor d $ TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ 1d6.`frlo Loring Well PUMP INSTALLATION 0 SYSTEM REPAIR El OTHER Prl 1 � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE �1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS7Le7� n Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation - b +Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casinjo-52>' 0^35 Specifications L M Public 1 Other © Delta Depth of Grout Seal Type of Grout Lg12C'e M Irrigation Approx. Depth d Eastern Surface Seal Installed by Repair Work Done v Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAMIADDITION M DESTRUCTION G [No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence Commercial— Other 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 Cl No, & Length of lines Total length/size FILTER 13ED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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 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 compensa- tion laws of California." The applican must tail fora"lequired inspections. Complete drawing on reverse side ` Signed Title:Title: .�_ _ _ Date: Z FO DEPARTMENT USE ONLY Application Accepted by — Cj Date _ Arsa . Pit or Grout Inspection by Date Final Inspection by Date `f 9 Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEE RECEIVED 9Y DATE PERMIT'NO. INFO -eSH /S . EH t3.26 IREV.t r n 51 �" �/ e-E 8 -0,201 —1 I I O lw 1 EH t{•?e 3 ttt111 I f Fr I►CJ S�