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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I; P O BOX 2009, STOCKTON, CA 95201 (209) 468--3447 i (Complete in Triplicate) '" ,ACJ 1 Application is hereby aladelto 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. u Job Address � e f)12 > City �� Lot Size/Acreage YP Owner's Name L' col —`CPW n Address rU' I f7 J-�- -�- Phone � bv-5 Contractor Address >� `` License N0. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPL GEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r_l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Welt Casing ) U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications M Public Ill Other ❑ Delta Depth of Grout Seal Type of Grout 0 Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done_ a Well Destruction ❑ Well Diameter Sealing Material & Depth Depth' Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION L3 REPAIR.YADDITION M DESTRUCTION M (No septic system permitted it public sewer is available within 200 lest.l Installation will serve: Residence— Commercial ._._, Other t Number of living units: Number of bedrooms •rte Charswef of $oil to a depth of`3 feet: Water table depth SEPTIC TANK 0 Type/.Mf®----.--.—....- ,Capacity .._.:-No. Compartments PKG. TREATMENT PLT.0 4_, Method L��roperty Method of DisposalDistance to earest: Well Foundation Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Siwe Number SUMPS LI 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 raguiations 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 workman's compensa. tion laws of California." The applicant ust call for all r;qu' pections amplete drawing on reverse side. _ te r Si Title: _ _{17� �, o..�� T�. Date: D ARTMENT USE ONLY q 1 Application Accepted by Date _4 �" ! V Area Pit or Grout Inspection by Date Final Inapectiori;by� Data Additional Comments Y � Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE CK f INFO AMOUNT Ot1E AMOVN7 REMITTED CASH RECEIVED BY // DATE PERMIT NO. E11 14-M. x�