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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMLHEALTH DIVISION P 0 BOX 2009, ST001TON, CA 95201 (209) 468-3447 PERMIT EXPIRES 1 YEAR VROM DATE ISSUED (Complete in Triplicate) Application Is hereby miude,to San Joaquin County for a permit to construct and/or install the work herein described. Thin application is made In compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rulelillfamd Regulations of San Joaquin County Public Health Services. Job Address '?SS 3 6/4, Cittyy� �i. /7< Lot Size/Acreage Ownei s Name ��` " Address �_5 S J /'— '✓_'� /i � Phone Contractor_.,2"v _ Address -S f1'� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out or 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 _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing {J-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications Q Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 0 Initiation —.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ InWell Destruction O Well Diameter Sealing Material a Depth – i Depth _ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION g DESTRUCTION CI (No sepue system permitted it public sewer is `^+ Installation will serve: Residence _ Commercial L Other lavailable eww,lntn6in//Wf.�leel.l Q Number of living units: _ Number of bedroomsyNl</a► .1�,1 1. �,U,f�fr(f Vit✓ham , �` Character of soil to a depth of 3 feet: r7�h Wafer table depth�b 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the Son Joaquin County (, Home owner or licensed agent's signature cenifies the following: "I cartify that in the performance of the work for which this permit is issued, I shall not , employ any person in such manner as 10 become subject to workman's compensation laws 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 persona subject to workman's compensa -.lion laws of California." The applicant�must��call for all required ins pecti/o�+s. Complete drawing on(r�r or" side. 'Signed Xi { ii,l +��H Title:, _.�,.LG.Ii z _- Date: lit FOR DEPARTMENT USE ONLY Application Accepted by z "' �5"'�?F� Dal e �yr Area / Pit or Grout Inspection by Data Final Inspection by, Dets� /7 i .Pdditional Comments: 'Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O SOX 2000, STOCKTON, CA 85201 FEE AMDVNT DUEAMOUBVNT REMITTED CASH RECEIVED GATE PERMIT NO, r�yi U Gaa / �JG� / 7 • EN 111AEV.�rnmr 11/ 111961 EN^.m.ai