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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA- 95201 y ' (209) ' 468-3447 R PROM DATE J§S (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. Job Address + 7 _ City fF&ctica e) Lot Size/Acreage Owner's Name _ .�t°1. f d;w Address _ S�'h /, Phone Contractor % r-e(t Address._.___P _--_ ad S` © License No - 4 Phone --_X?�t- --- TY-PE-OF-WEL-L/PUMP,- ----, _NEW.WELL.❑ _- -- --W.ELL_AEPLACE.MENT, n,-_ „DE.Al_kq TION,.C1.Out of Service Well ❑ PUMP INSTALLATION ❑f SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE.10 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE F FOUNDATION `'~ ' AGRICULTbRE WELL OTHER WELL PITS/SUMPS INTENDEO':4J'SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS +L] Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation '" 'Dia. of Well`Casing - U Domestic/Private ❑ Gravel Pack- ❑ Tracy Type of Casing Specifications I M Public Cl Other © Delta t Depth of Grout Seal Type of Grout r CI IrnOation •,..Approx,'Depth 0 Eastern - -Surf ace-Seal-Installed-by---=-- --•- --- ------ k Repair Work Done U Type of Pump H.P. I State Work Done'— Well one _Well Destruction O Weil Diameter i Sealing Material a Depth Depth Filler!iNaterial' i Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION •REPAIR/ADDITION Cl DESTRUCTION-0 (No septic,system permitted if public sewer is r i availible<within 200 feet.) Instellation will serve: Residence ✓Commercial ,-Other > d f Number of living units: A- Number of bedrooms Character of soil to a depth toot: s I- # Water table depth + SEPTIC TANK Yr 'wo/Mfg 92 L ' Gn �cd -G__Ca cit `w pa y_-- No:CompartRlenta-•-- PKG. TREATMENT PLT. Ll , , Method of Disposal Distance to nearest: Well [L Foundation Property Line _ f LEACHING RINE No. & Leng3h oflinesTotes length/sire FILTER BED ❑ x Distance to'Aearest: Wall- Foundation _ Property Line SEEPAGE PITS 1.1 Depth 4. 5i:e / Nu bet l Fy SUMPS ; " " $t F vf!Distanca'toiiearest " 1Nill__L0_Q:'�FouhdatioA(a a Property Line�� r s DISP'AAk PONDS- _ ''o �' t I hereby cenify that I have prepared-thit application and that the work will be done in accordance with San-Joaquin county ordinance's, state-laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's si®nature certifies the following;1'I certify that in the performance of the work for which this permit is issued, I $hall not employ any person in such manner as to become subject-to workman's corriponsoiion laws of California." Contractor's hiring or sub-coritracting-'signsture certifies the following: "I cartify,that in the performance of the v4ork for which this permit is issued. I shall employ persons subject to workman's compensa- tion laws of California." The applicant musi tall for,all gwred inspections. Complete�drawwng:on reverse side, Signed r.M sx �. Title: Date: C ' R D RTME USE ONLY Application Accepted byDate vl Ar Pit of Grout Inspection by Date FinaE In:pection by Date Additional Comments. Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 65201 .. PEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED By DATE PERMIT'NO, EN 144 (REV. ^ W04 AA