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a r. APPLICATION FOR PERMIT . / SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION r 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 4 PERMIT EXPIRES I YEAR FROM D S ED (Complete in Triplicate) 4Y P Application in hereby made'-to "a 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. qua 1G r + a.5--- �V�� ! +��fJ �� City It f`d� Lot Size/Acreage t�Job Address ,, , -MA4(_G 1 dV V1L C i_1 L P S#cr Phone r Owner's Name C1 01) l S' ,-,Contractor �«y� Address F License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DEST N OT Out of Service Well 0 PUMP INSTALLATION ❑ �. . SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL FLD. PROP. LINE + FOUNDATION - AGRICUL. LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO AREA CONSTRUCTION TIONS n Industrial ❑ Open Bottom Manteca Dia. of Wa1I Excavation of Weli Casing i 11 Domestic/Private ❑ Gravel L7 Tracy Type of Casi g_ Specifications I'1 Public r f-1 Delta' Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern _ Surface Seal Installed by Repair Work ne L] Type of Pump _ Y H.P. State Work Done Well`Destruction O Well Diameter Sealing Material iDepth Depth t biller Nater i Depth ' TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADOITIO I 1 DESTRUCTIONtNo pric system permitted if public t valla Is within 200 feel-I installatio serve: .Residence— Commercial_ Other Number o1 living un! w Number of bedrooms Character of soil to ar depth of Water table depth SEPTIC TANK O ' Type/Mfg Capacit No. Compartments PKG. TREATMENT PLT.Q Method of Disposal Distance to nearest: Well oundation Property Line ------------------------ i LEACHING LINE ❑ No. b Length'of tin el length/size FILTER BED 0 Distance to est: Well -Foundation rty Lina SEEPAGE PITS 'Depth Size Number SUMPS ,L l Distance to nearest: Well -- -_Foundation- Property Line DISP PONDS ❑'rl� . arsby 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 4 -,Home owner or Ncensed agent'i naiure 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 law'of CeGfornia."'Contractor's hiring or sub-contracting signature Cenifiaa the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persona subject to workman's compensa- tion laws of Califor . s � The applicant mu I or all required inspections. Complete drawing on reverse side. r x SignedI A Title: vL '► '� Data: _:aZzAs FOR DEPARTMENT USE ONLY Application Accepted byDate, ea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 0(resi i S hf4o u{i� Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO RECEIVED BY DATE PERMIT'N0. • EF01 l311.2E /44[RFY:I/r lS) 1 ' ti