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PIP APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 F- P O BOX 2009, STOCKTON, CA 95201 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) �Oaquink�county Application s ereby made to Safor permit to construct and/or install the work"herein described. This I application in made in campliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin county Public Health Services. ;1�} A Job Address ._ -- _ 1V #&1f7 ,49-,c' — , Lot Size/Acreage �7�7 Owner's Name 20 Address V ' """ Phone 7 Contractor Address 1 License No.c -Phone 4w✓1S7f1* TYPE OF WEL /PUMP' NEW WELL ❑ WELL RE ACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ Mont PUMP INSTALLATION C SYSTEM REPAIR CI �OTJH�ER C7 � �ring Well r❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � DISPOSAL FLD / PROP. LINE �r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION I� Ci lndustriei ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 171 Other fl Delta Depth of Grout Seal Type G out I I Irrigation —App►ox. Depth 1 1 Eastern Surface Seat Installed by c �� Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Welt Diameter Scaling Material 3 Depth Depth Filler Material f1: Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/AODITION l I DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other _ Number of living units: jolqrw. -w XPIK D Character of soil to s deptWater table depthSEPTIC TANK ❑ Mfg 8X;trod h ity No. Compartments PKG. TREATMENT PLT. ❑ permit may MY@ 8X{e ro " � t`�� Method of Disposal . Distanncc4p rtg� r � y r, 4 ti � Property Line L" LEACHING LINE Cl No. b t�gslJl�JRr pihtrt Total length/size FILTER BED 0 Distance to nearest: Well Fovnaation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation 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 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 not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature l 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 C rnla." The applicant call f all requir i C n91Cote dre ing on reverse side. Signed _ Date: `•' �"`�! `. FOR EP TMENT USE ONLY r- Application Accepted by �`' Ali Data Area / — Ph or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to; Sao Joaquin County Public Health Services Environmental Health Permit/Services 445 N Stat Joaquin, P 0 Box 2009, Stka, CA 95201 y FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY OAT INFO PERMIT'NO. ' 8 °° I M ta•z•IaEv.,,a s, .2, Ear N-2a L