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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -� ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 RECEIVED P O BOX 2009, STOCKTON, CA 95201 N i 1 V 2 3 19912 SAN JOAQUIN COUNTY PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r',JBL;C HEAI_TH SERV)CES (Complete in Triplicate) I."AIRONMENTALHEALTHDiVId;�)I Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This 1 application is made in cceWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �fr8�E.�,,3��,p� ��sQ L Ll�� 1!� City ��< Lot Size/Acreage Owner's Nome%� S&k S Addressvspoi G_Ay1 1f�__6'j Phone Conhactor L. Address Licensee NNoo.. .AS76--Phone 4k4-9RR TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well O _ PUMP INSTALLATION O 1SYS_T_EM'REPA_IR OTHER O Monitoring Well O DISTANCE TO NEAREST:`SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE v FOUNDATION` AGRICULT.URE-WELL--EL OTHER WELL PITS/SUMPS fl� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION �n industrial O Open Bottom O Manteca Tia. of Well Excavation Dia. of Well Casing bL Domestic/Private O Graver Pack/___C7 Tracy,_.:_,�:'_. Type of Casing-__ Specifications - I'] Public)/_ 1-1 Other (1 Delta Depth of Grout Sear Type of Grout I I Irrigalroh(r _-ApproxfOepth ! I I Eastern Surface Seul Installed by P F Pu P Repair Work Do U Type H.P. ' � _ State Work Done , Well Destruction "~--O/Well Diameter Sealing lfaterial'i Depth 1e ' Depth Ib b s Filler Material i Depth TYPE OF SEPTIC WORK:/NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I f lNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residents_ Commercial_ Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: .r Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number _SUMPS LI Distance_to rNsrsisi: Wall- - Foundation - - -Property-Lina. \ T DISPOSAL PONDS G _ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and rules and regulations of the San Joaquin County I Home owner or licensed agent's signatur.e certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell not amploy any per n such manner as to;become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies tM f i :'I unify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tanlaws Cal Ia.',I Thi ipplica t call for allr` red irion s s. Complete drawing on reverse side. = t� Signed Title: FOR DEPAATMENIP USE ONLY j I Application Accepted by Date// Areae Pit or Grout Inspection by I Data Final Inspection by Date �3 a Additional Comments: F I . Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE A OUNT DUE AMOUNT REMITTED K ECEIV O BY ATE PERMIT NO. INFO . EH 13-24 111EV.t i#15)• � t✓ h - v/7 �iX //! �� .�