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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION, P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EX.p19919, I_YEAR ?ROM DATE ISSUSD , (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork 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. j� Job Address + Lot Size/Acreage City . T Owner's Name _ r Address 1 Phone Al - ContractorAddres _ Licse N - Phoneme TYPE OF WELL/PUMP: 3 NEW WELL ❑ WELL REPLACEMENT CJ DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ ► SYSTEM REPAIR 0 OTHER ❑ Monitoring Well n " DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION -AGRICULTURE WELD OTHER WELL SPITS/SUMPS ,= INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (A Industrial t ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing U Domestic/Private. ❑ Gravel Pack ❑ Tracy Type of Casing Specifications s� ID Public f-1 Other ❑ Delta Depth of Grout Seal Type of Grout Cl Irrigation ! d �,.Approx. Depth C1 Eastern Surface Seal Insialle'd by" Repair Work Done U ✓Type of Pump H,P. State Work Dorie Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler`Material'i-Depth" ` TYPE OF SEPTIC WORK; NEW INSTALLATION CI REPAIR/ADDITIONNK DESTRUCTION CI (No septic system permitted it public sewer is � available within 200 feat.I Installation vw'G serve: Residence X Commercial_ Other x Number of living units: ^/_ Number of bedrooms f?p f Character of.snit to a depth of 3 feet: _� �J rC1/ti/1 ,, „- "` �� Water table depth `_ I SEPTIC TAN0r;3'I6M Type'/Mfg Capacity No. Compartments PKG. TREATMENT PLT, C'1 '� I Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size �6 FILTER BED { 171 Distance to nearest: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS k LI Distance to nearest: Well , Foundation _ Property Line 7 DISPOSAL PONDS - ❑, i I hereby certify that I hove prepared this application and that the work wi$l be done in accordance with San Joaquin county ordinances, state laws, and rules and regulitions of the San Joaquin County t Home owner or licensed agent's signature certifies the following:— 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•Ctiiiforni'a." Contractor's hiring or sub-contracting signature j 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 m st call for all required ' ctions, ompie drawing on.reverse aide.,,..,f.. Signed r y - Title: �� 1 --- - Date., /rn .w �KF,1,! �ARTMENT V5E ONLYApplicationAccepted by _ ��t,J,nAPA6n.,tir.nN___— Date .� ��'�l� . Area y" r Pit or Grout Inspection by Date Final Inspection by ! Date Additional Comments: , r 1 7 b Applicant - Return all copies to: iSAN JOAQ IN COUNTY PUBLIC HEALTH SERVICES �_i� 'J '. ^• .� ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES a C 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 fi r,f �rr r�✓✓ rYl>�, i IFEEO AMOUNT DUE AMOUNT REMITTED LCASH' i RECEIVED 9Y DATE . EH 1� WtV, ALL