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APPLICATION FOR PERMIT 3 - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIiENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 w P O BOX 2009, STOCKTON, CA 95201 L� RMIT E%PIRES I YEAR FR MDTE II (Complete in Triplicate) 0 Application is hereby merle to Saa�Joaquin County for a permit to construct and/or install the work herein described. This application in made in cce>pF_ 330llancelvith San Joaquin County Ordinance No. 549 and 1862 and Joaquin County Public Health Services. the Rules and Regulations of San Job Address +- le!;."o XC421MAddress City f? (! Lot 31ze/AcreageOwner's Name I` l0�' l Phone Contract l "Ir Address 6_111 License No. d e�—�.� phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION Out of Service iJell ❑ , -PUMP INSTALLATION ❑ SYSTEM REPAIRMonitors W ❑ OTHER ❑ r+13 Well ❑ 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 C7 Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing I fel Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 11 Public 1.1 Other J f1 Delta Depth of Grout Seat type of Grout—_ I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done— Well Destruction Well Diameter— Sealing Material.& Depth n *p, Depth,_„�y ,_ tiller Material i Depth `v TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDtTION i I DESTRUCTION I I (No se tic System P permitted it public sewer is Installation will serve. Residence� Commercial., Other available within 200 feet.) Number of living unite Number of bedrooms Character of soft to a depth of 3 fest: Water table depth SEPTIC TANK. 0 Type/Mfg + Capacity No. Compartments ' PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line - LEACHING LINE C'1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth 1 Size` Number t'1 SUMP5LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the Sen 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 parlor a Of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Calif The applitan use cat)for all quired in na. Complet;711 .ng on rever side. Signed : Date: a�,l DEPARTMENT USE ONLY � Applicetion Accepted by Date res Pit or Grout Inspection by Data Final Inspection by ,, Date`7,r Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED '~ INFO CASH RECEIVED BY DATE PERMIT*NO. • IN 17-24 IREY,it to sl k/ 0 o-o 0 ' 14.26V V IN 1L-