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-nom �ti 'Sip i APPLICATION FOR PERMIT s,1J �� 1 ti1G � N� S" JOAQUIN COUNTY PUBLIC HEALTH SERVICES�C 4�' '� ENV I RONIOENTAL HEALTH DIVISION1 j 445 N SAN JOAu PHONE {209IN 4C$-3420 ) 4� P O BOX p 2009, STOCKTON, CA 95201 .A� � 9l G ti d PERMIT MIRES 1 YEAR FROM DATE I S SUED v (Complete in Triplicate) l %`�'� Appcation is hereby made 1:0 $aAJoaqulA County for a permit to construct sad/or install the work herein described. This application is made in coWlianceivith San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Serv1 es. n ' Job Address t City Lot Size/Acreage P��Owner's NameC:�(� + Address s-/ Z �u 1 Phone '^�t" Ww"^1iy'+'A r^ �`�+i ( ... '.y-�.+ a4e+.w+'+.+�¢T p.��..•- .—...J.....r..-(� �ic Contractor Address) J License Na a Phone r✓ TYPE OF &WELL/PUMA,- NEW'%W: ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well 0 PUMP INSTALLATION ❑ S TEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ! FOUNDATION k AGRICULTURE EL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA { STRUCTION SPECIFICATIONS- ❑ Industrial ❑ Open Bottom - ❑ Manteca .A D' . of Well Excavation � Dia of Well Casing Cl Domestic/Private ❑ Gravel Pack —t U. 0-Tracy pe of Casing_ ' - Specifications I'1 Public- _ ' El Other i r fl" epth of Grout Seat Type of Grout --- S, I Irrigation Approx. Depth I I stern. Surface Soul Installed by i i Repair Work Done U Type of Pump H.P. State Work Done*Will Destruction ❑r° -Well_Diameter; Sealing Ma_terial-A Depth r tiller Nater) a Depth ! TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIRIAODITION I DESTRUCTION I I (No septic System permitted if public sewer is # available within 200 feet.) Installation will serve: r Residence_ Commercial_ Other ; Number of living units: Number of bedrooms r E Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK ❑ Type/Mfg -1/160 Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation Pr r Y x ' ops Line —ow jut LEACHING LINE i❑ No. 3 Length of lines T al length/siz FILTER BED ❑ Distance to R nearest: We11 I Foundation Property Line ' t I ' 1 SEEPAGE PITS .1 k7 e = -mbor' ` i SUMPS Lt Distance to neo t: Well undatian Property Line DISPOSAL PONDS ❑ _ I hereby certify that I have prepared this aipplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and, rules and regulations of the Sen Joaquin'county ', f i t i Home owner or licensed agent's signature eertifNs 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 applicant t call for uired in ctions.'Complete drawing on reverse side. Signed Title:! ¢ bate: OR DEPARTMENT USE ONLY Applicetlon Accepted by - .!-Date Area ` Pit or Grout inspection by ~ Date Final Inspection byData �` �Z i Additional Comments: J / x , Applicant —Return all copies to: San Joaquin County Public Health Services Bovironmerit:ti3:-H-eaj.th Permit/Efervices s 445 N San Joaquin,.-P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA//SH RECEIVED BY DATE Q PERMIT'N0. . EH e2/'IIIEV.I III V f �