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{ APPLICATION FOR PERMIT SANrJOAQUIN COUNTY PUBLIC HEALTH SERVICES :( ENVIRONNMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ;) P O BOX 2009, STOCSTON, CA 95201 PERMIT EXPIRES I YFAH FROM' DATE ISSLIED (Complete in Triplicate) Application is hereby made.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 and the Rules and Regulations of San Joaquin County Public Health Services. A�` Lot Size/Acreage lQ Job Address . J s�a1 - _ City C�Owner's Name R f �larJ Address 4�^` Phone �. — Contractor a ooAddress — 0'M� ,+ 1'300 4! License No. Phone ell 0 TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out offs ging Well ❑ ..PUMP-INSTALLATION .❑ SY57Eful REPAIR ❑ OTHER ❑ N � 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 E) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing Specifications C1 Domestic/Private ❑ Gravel Pack + E3 Tracy Type of Casing— , - t} "�" Type of Grout I'1 Public 1-1 Other Cl Della Depth of Groes[ Seal I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done [.7 Type of Pump I H.P. Stats Work Oona-_y - Wall Destruction ❑ Well Diameter's Sealing Material ac Depth Filler Material i Depth r f" Depth - TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted it public sewer is �. available feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: ` Water tibia depth SEPTIC TANK. ❑ Typa/Mfg Capacity No. Compartments PKG, TREATMENT PLT.❑ ` . Method of Dispose) Distance io!neareet: Well v�eFoundation `90`" Property Line /d` X 3a� Total length/size 1 " LEACHING LI E C1 No. i Length of lines BEO Distance tainearest: Well d"', Foundation ®F Property Line ZO SEEPAGE PITS I I Depth j Size Number SUMPS Ll Distance to nearest:: 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, 1 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 compenss- tion lawn of California.••• ;. The applicant all for all uirad inspections. Complete drawing on rever side. Signed Title: �� _ Date: �Xe ENT USE ONLY '4=— rea D-Z Application Accepted by Data [ Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: t Applicant - Return all copies to: San Joaquin County Public Health Services A Environmental Health Permit/Services 445 K San Joaquin, P 0 Box 2009, Stkn, CA 95201 , FEE C ' RCEIVED'BY DATE Z PG�EjR M OCASH INFO Em X767- t Et 11.nVY,00i .