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APPLICATION F6.4- PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA. 95201 J209) 468-3447 u RIMIT .EXPIREI )[EAR FROM DATE 15hJUED l T (Complete in Triplicate) Application to hereby made to San Joaquin County,for-a permit to construct and/or install the work herein described. This Application is made in coa>pliance vith San Joaquin;County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. ,. Job Address _ �b4/rtiS__.,_, City Lot Size/Acreage Owner's Name rt^ , �. Address S--r'yg`___ _ Phone Contractor--'T- �-- _i�i�i!L c.� Address License No. y R Phone��`^t TYPE OF WELL/PUMP; r NEW WELL ❑ WELL REPLACEMENT .0 DESTRUCTION ❑ Out of Service Well ❑ ' PUMP INSTALLATION,❑ R SYSTEM REPAIR ❑ OTHER p Monitoring Well C3 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 f7 Industrial i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack q-Tracy r: Type of-Casing 51ie+silfcations A Pablit; Cl Other l] Delta Depth of Grout Seal Typo of Grout �,-- CJ Irrigation , ___:'_1.Approx. Depth ❑ Eastern Surface Seal Installed by - =< r Repair Work Done (3—`Type of Pum T P H.P. State Work Done w ` Wel(.Destruction 0 Wag Diameter Scaling Material i Depth d Ort �w Depth Filler Material 4-Depth TYPE OF SEPTIC WORK:,_ NEW INSTALLATION REPAIR/ADDITION Cl DESTRUCTION ❑�No ieptic system permitted if public Sewer is available,within 200 festA Installation wip serve: Residence J Commercial Other ^ ` f; Number of living units: Number of bedrooms n l Character of&oil to a dept of 3 feet: > �cf�Water table depth , SEPTIC TANK. Type/Mfgc(o Capacity_±-e�CSS"fes` No. Compartments i` PKG. TREATMENT PLT, C1 4 Method of Dittpgsal _ Distance to nearest: Well 1 O0 Foundation.` Property.,Lina 3`L LEACHING LINE No. & Length of lines 6A " Total length/fixe FILTER BED [1 Distance to nearest Well Fnu�dation` «f Property LineQ� Ii SEEPAGE PITS V'Depth SireNrmb -�-�---��!�, �.. tier mo SUMPS LI Distance to nearest: Well o = Foundation_ _/ Pro DISPOSAL PONDS ❑ perry Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stets laws, and rules and regulations of the San'Joaqufn County *ty ' d` a. ,� ; 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 shat!not i employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring at 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 must coil for aA required inspections. Complete drawing on reverse side. + Signed Title: .r Date. FOR DEPARTMENT USE ONLY Application Accepted by Date r I r Area or Grout Impaction by` ate b _ Fina! Inspection by � � ' n Date Additional Comments: yr Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 88201 Y �! FEE AMOUNT DUE AMOUNT REMITTEDCK r INFO CASH RECEIVED BY DATE PERMIT'NO. e . EH 13•2I fREV. G.�. •rte ��-�13/ - EH 31.20 ^ x