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,E APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 �+ 1r rf Alorr0 fig P O BOX 2009, STOCKTON, CA 95202 tf lttf 7 u PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is 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 CountyPubli H alth Servi�cesss..� /Job Address IIG f `� _. Cit Lot Site/Acreage �1 Q *wnor's Name -y:1 Address 4 O LI u � +"• Phone �y Contractor � J Il Address License No. Phone TYPE OF WELL/PUMP. it NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service.Well 0 PUMP INSTALLATION C3SYSTEM REPAIR LlOTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i f-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Cl Public EI Other n Delta Depth of Grout Seal Typi of Grout t I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work pone U Type.ot Pump H,P. __— State Work Done , i Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Maters TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION f DESTRUCTION o septic system per 1 public sewer is ailable within eet.I Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of'i3 feet: Water table depth SEPTIC TANK 0 Type/Mfg city No. Compartments PKG. TREATMENT PLT. 0 jp Method of Disposal J r Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 11 Lengt Ines Total length/size FILTER BED ❑ Dist to nearest: Well Foundation Property Line ,I SEEPAGE PITS I I depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DIS AL PONDS I❑ Ii rt isreby 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 SanlJoaquin County Home owner or licensed agent's signature cenifies 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." II:I The applicant must call for aH required inspections. Complete drawing on reverse side. �t,! Signed X 'h Title: Date: • �Z _9 _- II FOR DEPARTMENT USE ONLY. Application Accepted by Date -0 ' AreaAle Ali i Pit or Grout Inspection by II Date .Final Inspection b al Data Additional Comments: ii Applicant - Return all copies to: Sin-Joaquin County`Public Health Services i` Environmental Health Permit/Services R 445 N San Joaquin, .P 0 Box 2009, Stkn, CA 95201 FEE AMOUT DUE AMD NT REMITTED CAS1 teCEIVED BY DATE PERMIT'NO. INFO EH 13.24IREV.+/n51 �4/51 EH 1.26 /// II