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APPLICATION FOR PERMIT SAN WQUIN COUNTY PUBLIC HEALTH 9VICES ENVIRONMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PEMIT METRES 1 YEAR FROM DATE :dSSUED (Complete in Triplicate) !! Application ie here made to San J !! !� � App by Joaquin County for n permit to construct and/or install the work herein described. This F application is made in compliance vith San Joaquin County Ordinance No. 519 and 1862 and the Rules and Regulations of Seas Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name C t r Address I Phone 1 Contractor Address '!z , II License N4 Phone TYPE OF WE /PUMP: NEW WELL ❑ WELL AEPLACEMENT 1-1!JI ! DESTRUCTION CI Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well I DISTANCE TO NEAREST: SEPTIC TANK ,/24 SEWER LINES 52 DISPOSAL FLD.aa PROP. LINE . FOUNDATION .5�'� AGRICULTURE WELL _Z;_� OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C! Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i fl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing ! L Specifications 222 1 I'1 Public Cl Other n Delta Depth of Grout Seal !' #' Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done U Typs of Pump H.P. !!�S�. Ie ork Done Well Destruction 0 Well Diameter Sealing Material i Depth �� . `,L-.- s } Depth Piller Material i Depth II I S�� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I INo septic system permitted it public sower is ` L ! 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 C) Type/Mfg Capacity ! No. Compartments PKG. TREATMENT PLT. ❑ "!° !' Method of Disposal Distance to nearest. Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total leripth/size FILTER BED 0 Distance to nearest: Well Foundation property Lina SEEPAGE PITS I I Depth Sire Number' I SUMPS Ll Distance to nearest: Well Foundation i ropsrty 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 rogutations of the San Joaquin County I ' Home owner or licensed agent's signature conifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not 4 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature unifies the following: "I certify that in the performance of the work for which this permit is issued, 1841 employ persons subject to workman's compensa- tion laws of California." The applicant t f all ► tt_o�*. mplete drawing on re rse side, I. Signed X Title: ee Date: FOR DEPARTMENT USE ONLY! Application Accepted by Date 11 Z 5 Z Area / Pit or Grout Inspection by Date Final inspection by 'r Date 7 �i3 Additional Comments: 0/(� AZ - A�/ 7 g 3 Applicant - Return all copies to: Sa Joaquin County Public Healthn'Services Environmental Health Permit/Servi'ces d; 445 N San Joaquin, P p Box 2 ; n, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH ! BY ,�� DATE MIT-NO. . EM13-241PIEV.I/P1al WtA �$a &ZD /� i� �'I! /rZ-/�5kz EH 14.20 f