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APPLICATION FOR PERMIT C SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 'ENVIRONMENTAL HEALTH DIVISION P O BOK 2009, STOCKTON, CA 95201 (209) 468-"47.3q--i& PERLtIT ESPIRTS I Y��Q�¢ ��q�`E 155ulm (Complete in Triplicate) Application is hereby mode-to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in cotspliance with San Joaquin County Ordinance No. 549 ond.1862 and the.Rules and Regulations of San Joaquin County Public Health Services. B �r 1739 S'✓lt:fCll ____ City mock*yv Lot Size/Acreage �7 �� _ Job Address • Owner's Name t Address _ �7, �� 'Si rtePhone to 6- 190 Address License No. Phone T"FFE OF WELLIPUMP: NEW WELL.❑ WELL REPLACE ENT 71 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM EPAIR ❑ OTHER ❑ Monitoring Well CZ DISTANCE TO NEAREST: SEPTIC TANK SEWER INES -DISPOSAL FLD, PROP. LINE FOUNDATION AGRICUL RE W LL. OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA C STRUCTION SPECIFICATIONS r_l Industrial ❑ Open Bottom ❑ Manteca ,1 � a. Well Excavation Dia. of Well Casing s - CJ Domestic/Private Cl Gravel Pack 0 Tracy . Type of 'sing - ..Specifications ❑ Public 1-1 Other 0 Delta E __Depth.of Gro Seal Type of Grout V" M Irfipation —Approx, Depth .1 3 Eastern Surface Seal Ins ed by Repair Work Done 0 Type of Pump P. tate Work Done _ Well Destruction ❑ Well Diameter Sealing Material k Depth Depth' ` Filler Material & Depth + TYPE OF SEPTIC WORK: NEW INSTALLATION L0 REPAIRIADDITION 0 DESTRUCTIOn lNo septic system permitted if public sewer is Installation will serve: Residence._._.:P Commercial— Other - available within 200 feet.) Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. Cl _ _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L-1 No. & Length of lines Total length/size FILTER BED n Distance to nearest. Well Foundation Property Line i i SEEPAGE PITS ( I Depth 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 ragul0ona 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 i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I 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," i /The appN must I for-all requi -inspgctions,-Complete drawing on averse side.w_ _ /Signed .� Title: �A�1 Date., ^ I FO DEPARTMENT USE,ONLY, Application Accepted by � ` ase = ' f Area Pit or Grout Inspection by Date Final Inspection 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 95201 FEE INFO AMOUNT DUE AMOUNT REMIT-tE0 � FH �X RECEIVED BY DATE PERMIT NO. . EHt]-Z�tREV.riKbl .� 39�� ' . � :426 l�7