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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 3 P O BOX 2009, STOCKTON, CA 95201 (209) 468-34473 0 PERMIT RILPIRES t YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This I application is made incompliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. Job Address `' �Dl Cla' City _ Lot Size/Acreage l Ace 7 Owner's Name Addres r+ Q�f Phone Ir—kV/4 Contractor � 'Address �� Y License No. Phone TYPE OF W L/PUMP. t. NEW WELL ❑ 4�, WELL REPLACEMENT ❑ DESTRUCTION Out of Service Nell ❑ _ PUMP INSTALLATION;❑\i. . \ �_ _ SYSTEM REPAIR ❑ O_THER ❑ Monitoring Nell ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL�FLO. PROP. LINE " FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - Intlustrial CJ Open Bottam . ❑ Manteca Dia. 01 Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M PiIblic Cl Other ❑ Oeha Depth of Grom Seal a Type of Grog( ❑ Irrigation _.Approx, Depth ❑ Eastern Surface Seul Instsllad by I �,Rapair Work Done U Type of Pump ' I . H,P. StateWorkDone _ P terlal i Depth -� Wall Destruction ❑ W4111 Diameter 1h�.y -- Depth " ` er _...h TYPE OF SEPTIC WORK: NEW TNSTAL'LATION❑ REPAIR/ADD 10 TI � o e is system permitted it public sewer 7 'I a within 200 feet.) i er ther hays_ x Instillation will verve: Residence_ Commercial 1�py Cher plret��ttiifhouf" " Number of living units: __ Number of bedroom�rn "r�,n cpmNOW ori =-- Character of w8 to a depth of 3 feet: ns e� able depth SEPTIC TANK: ❑ Type/Mfg AP11 No. Compartments PKG. TREATMENT PLT. C1 Method of Disposal Distance to nearest: Well foundation Property Line I I LEACHING LINE ❑ No. & of lines Total length/size FILTER BED I,tanca to nearest. Well Foundation Property Lina SE PITS I I Depth Sire Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinanc tate laws, enc rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall no employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contiecting 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 compense tion laws of if nla." The apple nt r at ua for ai oq tsps ions. Complete drawing on reverse side: Signed Title: Cl N Date: r 2— /l (A1.� F DEPARTMENT USE ONLY Application Accepted by —`oma =4C •^ &A Q&.6— Date Area r Pit or Grout Inspection by Date Final Inspection by Date Additional Comments Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOE 2009, STOCKTON. CA 95201 FEEAMOUNT DUE AMOUNT REMITTED Ck RECEIVED By DATE PERMIT NO. INFO CASH ENn.i4Illy.l,nal Co0-0° or) Co 3as� m� - �a 91 4i ( 3'