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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 f (209) 468--3447 ,� { y YEAR PROM DATE (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 in trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San ' Joaquin County Public Health Services. ` Job Address ��C� /`�� City �� Lot Size/Acreage Owner's Namo�/ "_ Address �� Phone �"' �12_ I V-8—0017 Contractor �!� Address 4!SdCp_kC. � `3~ License no. -! _Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION,9. SYSTEM REPAIR g_ OTHER ❑ Monitoring Well G7 r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public CI Other ❑ Delta Depth of Grout Seat Type of Grout I 173 frngation ;;Approx. Depth ❑ Eastern Surface Seal Installed by i Repair Work Done U Type of Pump H.P.. State Work Done _ Well Destruction 0 Well Diameter Sealing Material tr Depth � Depth 'Filler Material i Depth TYPE OF SEPTIC WORK; NEWINSTALLATION 0 REPAIR/ADDITION M DESTRUCTION F-I INo septic system permitted if public sewer is 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: y Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Ll Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line. SEEPAGE PITS 11 Depth Site - Number SUMPS Ll Distance to nearest: Well Foundation' t Property Lina DISPOSAL PONDS .la 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 j rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following; "I certify that in the performance—df—W-4 work for which this permit is issued, I shelf not employ any person in such manner as to become subject to workman's compensation laws 4f.Cilifornia"Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, i•alialUempioy persons subject to workman's compensa-tion laws of California.,' The applictpt. >Kst call for all r2auired inspections. Complete drawing on reverse side:" - Signed `�J Title: _5��'AUC 1�"i ,•...... Date: FO DEPARTMENT USE ONLY 1l Application Accepted by - Date - - '�z- area y Pit or Grout Inspection by Date Final inspection by Date 3 Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2006, STOCKTON, CA 85201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASHCK # RECEIVED BY DATE PERMIT'NO. + EH 121(REV.r/K51 / / -