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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENViRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE MWED (Complete in Triplicate) 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and.Regulations of San Joatuia County Public Health Services. ��// /� /12 Job Address -2 2VZO / l_ /`rte __Y_ City Lot Size/Acreage Owner's Name -Address'. 9 2- Phone t Contractor h 44CAddress License No.30:57e-�Z� Phone 3683FM TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION � AGRICULTURE WELL OTHER WELL PITS/SUMPS .w. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E C1 Industrial t .❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing �r Cl Domestic/Private ❑ Gravel Pack n Tracy ��,Type of Casing_ Specifications 11 Public Cl Other ' Cl Delta Depth of Grout Seal Type of Grout I I Irrigation __._Approx. Depth l I Eastern Surface Seal Insialled by 4`, Repair Work Done 0 Type of Pump j H.P. State Work Done �+ Well Destruction ❑ Well Diameter Sealing Material i Depth. Depth filler No. r th TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITI N YT D TRUCTION I I (No,septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence &-.- Commercial— Other Number of Ihring units: —A— Number of bedroo s M Character of toil to a depth of 3 feat: ' f m � Water table depth 16 SEPTIC TANK. ❑ Type/Mfg t Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method_of_Disposal Distance to nearest: Well Foundation Property Lint LEACHING LINE ❑ No. & Length of lines Total length/size _ FILTER BED 0—Distance to`neartst: Well _ Foundation �� ? Property Line a � r t90 t SEEPAGE PITS i k th Sirs 1 Number SUMPS { Ll Distance to.neacest:— Well . Foundation r Property 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 regulations of the San Joaquin County "`"�"'�""' "" __ '_ 'r= Home owner to licensed apent'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 taws 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 personi subject to workman's compensa- tion taws of California,", The applies must call for all r�imdpeotions. Complete drawing on reverse side. a ,p� Sig _.Title: _CL�LlJs/!sf _._.._ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date - :9 21 Area d 2 ;4 Pit or Grout Inspection by t Date Final Inspection by Date f Addhbnill Comments: F Applicant - Return all copies to: San Joaquin County Public Health Services y� Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK INFO FEE AMOUNT OVE m AMOUNT REMITTED ;CASHRECEIVED BY DATE ZitERM17,NO. tHt3t4rltEv.miNmsm mIl . D � EH 14.20