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} APPLICATION FOR PERMIT , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES k 11 ENVIRONNNENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT -EXPIRES I YEAR FROM DATE I S (Complete in Triplicate) T.d./ Application is hereby made,to Son Joaquin County.for a permit to construct and/or install the work herein described. This application in grade in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and ReguLtions of San Joaquin County Public Health Services. X04 1b Address City G ►% Lot Size/Acreage , "f Address ��`�� _ Phone nar's Name YO, Cantractt►r �r L� ��'� __Address / 9;7 eAEL License Nol 0Z Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ D ON ❑ Out of Service Well ❑ # -PUMP'INSTALLATION ❑ SYSTEM REPAIR Monitoring Well C3DISTANCE 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 C7 Industrial ❑ Open Bottom - - ❑ Manteca Dia. of Well Excavation Dia. of Well Casing EI Domestic/Private Cl Gravel Pack 3 ❑ Tracy Type of Casing_ Specifications Il Public Cl Other '- Cl Delta Depth of Grout Seal Type of Grout ` I i Irrigation ____.Approx. Depth I I Eastern Surface Seat installed by Repair Work Done ❑ Type of Pump H.P. t Stat*Work Done_ Well Destruction _ ❑ Wail Diameter Sealing Material i Depth Depth:k Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public saw*( Is available within 200 feet.) `Installation will some: Residence Commercial— Other Number of living units: °Number of bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ ?I Method of Disposal Distance to nearest: Well Foundation Property Line Total fen th/size LEACHING LINE ❑ 'No' S Length of linea g FILTER BED Cl Distance to nearest. Well Foundation Property Line u SEEPAGE PITS 11 Depth Sue Number SUMPS LI Distance to nearest: Well - - -Foundation - - ---Property Line " f DISPOSAL PONDS ❑ ' r 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 workm_an's compensa- tion laws of California." ,i 1�T{he applicant t call for all required inspections. Complete drawing on reverse side. slide. y� ,7 P/^ -� / d may. �(5 eB� Title: �__�?' C�y� �1_� Date: Y�h I ! l_=:c fi h F DEPARTMENT USE ONLY C; Application Accepted by -" Date S � - Area ? � .. Pit tx.Grout Inspection by Date Final Inspection by Data /� ✓ max. . Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. t INFO . tH 13.24 irIEV.r/„!ire EH 14.20 '"J (� e I.