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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PEMIT EXPIRES 1 YEAR FROM DATE ISSUED _ (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application Is made In couplisnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San yJoaquin County Public Health�QS-ervicep..Jx� / - - Job Address ._�� _" f�J7 City �.ot Size/Acreage owner's Name ,QeQ� r!�C of l��ZLLAddress `- Phone X�[ G-S 7e L.S2y,�v ir-;;, � .�!'d1 �i �h " is FJwn i� �r13 - TYPE OF WELL/ P. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ of Service Well ❑ STALLATION ❑ SYSTEM REPAIR ❑ OT Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL F PROP. LINE FOUNDATION RICULTURE WELL OTH ELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA NSTRU SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Di Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other a Depth of Grout Seal Type of Groul ❑ Irrigation �.ADProz. D th" ❑ Eestarn Surface Seal Installed by Repair Work Done ❑ Type mp H.P. S[ata WorkDon Well Destruction ❑ ell Diameter Sealing Material a Depth .. Depth Filler Material i Depth STYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION LT DESTRUCTION 0 (No septic system permitted if public sewer is h available within-200 feat.) Installation will Neve: Residence. Commercia _ Other e' Number of living units: _L Number of bedrooms Character of aog to ■ depth 3 feet: Water table depth I. SEPTIC TANK- Type/Mfg 6 P_ G Cdnacty s // d No. Compartments + .� PKG. TREATMENT PLL ❑ - Method of Disposal Distance to nearest: Well Foundation Property Lina _ /LEACHING LINE C( No. g Length of lines44 �d Total length/size FILTER BED At Distance to nearest: Well, Foundation Property Lina , SEEPAGE PITS iG Depth � Sire i�;i tr 4. _ Number `. SUMPS LI Distance to nearest: Well Foundation Property Lina 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." 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 persons subject to workman's compensa. tion laws of California." The applicant ppmust��call for ell r 4/pired inspgctio omplete drawing on reverse side. Signed x/./�/P� /r E Title: �s F(KR DEPARTMENT USE ONLY Oil Application Accepted bydip Pit or Grout Inspection by Date Final Inspection Date Additional Comments Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 05201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO ``1 1` ^�` �,yCASH M �J r EEH s A.211 IREV.1i451 1 1�' .V`-� 11 � lit 1 r r IL '—