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• �" = =, +� �� APPLICATION FOR PERMIT ,x I� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 �1 P IST MIR9sR I YEAR VRQX DATE ISSUED (Complete in Triplicate) Application In 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. �� " 71 Job Address 0 cf5�� Lot Size/Acreage ! ' 1 it 7� Owner's Name�� _ Address !! Phone ` �� I A I� GDf 7T q� f�f hone 70 Contractor --_ Address �✓ 7®�t��I�i � � -f 11) TYPE OF WELL/PUMP: �� NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service Well 0 PUMP.IINSTALLAT10N ❑ SYSTEM REPAIR C1 OTHER ❑ n91Xl L� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack 0 Tracy .. Type of Casing Specifications M Public Cl Olhar ❑ Delta Depth of Grout Seat Type of Grout r-I leboation —.Approx, Depth ❑ Eastern Surface Said Installed by Repair Work Done U Type of Pump H.P. �Sf e Work Do a _ Well Destruction ❑ Well Diameter Sealing Material Z Depth (�" € DepthAajij� Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i❑ REPAIRIADDITION M DESTRUCTION G INo septic system permitted if public sewer is available within 200 feet.) installation will .serve: Residence _ _ Commercial— Other Number of living units: ;,Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Typo/Mfg Capacity No. Gompartmems PKG, TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Dista`nce to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ it 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 regulations 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 applica must call for r u' ns � pections. Complete drawing on reverse aide'. _ Signed Title: �T/�/�'�d1 Date: r Aw FOR DEPARTMENT USE ONLY �} Application Accepted b ! f?p P Y Date Eaa; Area Pit or Grout Impaction by II Date / F71"417 nn I lnspeeti n by patg�a Additional Comments: r /s 4/ ,/ r Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES IF ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES f ti 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 INFO AMOUNT DUE AMOUNT REMlTTEO CASH RECEIVED BY DATE PERMIT'NO. EN 13.24 tREV.1IK60 VO EH A-29 r ,tot) 15`733✓✓ /�4w 1 f }