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APPLICATION FOR PERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 Y . (Complete in Triplicate) Application is hereby made to San Joaquin County -for a permit to construct and/or inetall the work herein described. This application is made in compliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San k Joaquin County Public Health Services. Job Address Z4MZ City .4.1 Lot Size/Acreage —3l f Owner's Namedress Phone 49 Contractor Sddrt ss a?� h,�.L��/ '- License No.�.Phone TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT n DESTRUCTION 0 Out of Service well. ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . ___ DISPOSAL FLD. PROP. LINE FOUNDATION fes/ AGRICULTURE WELL OTHER WELL PITS/SUMPS Z6C INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION 171 industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack 0 Tracy Type of Casing C— Specifications A Public Cl oyer ❑ Delta Depth of Grout Seal Type of Grout CI lrripation 3.Approx. Depth ❑ Eastern Surlscs Soul Installed by ! Repair Work Done 11 Type of Pump M.P. _. Z State Work Done_ t Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIRIADDITION M DESTRUCTION G Ilio septic system permitted if public sewer is ' available within 200 last.) Installation will serve: Residence— Commercial— Other Numbet-of iivinq-unitc Number of.bedrooms - Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT,O Method of Disposal �o f Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. b Length of lines Total length/size 4 : f FILTER BED n Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line [ DISPOSAL PONDS ❑ Ih 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 I rules and regulations of the Sen 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 epplica us requi . Complete drawing on reverse ide. Signed ills: Date: DEPARTMENT USE O LY Application Accepted by hA Date 90 Area Pit or GroutInspection by ate d Final Inspection by -z-; Dams 3 Additional Comments: ] !'I 1A"f" Applicant — Return all copies to: gAN JOAQUIN COUNT PUBLI BALTH SSRVICgS IF ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 SOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. EH 1i24INEV.I/K4m , 0 0 &6f