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_ APPLICATION FOR PERU. _- --- SAN JOAQUIN COUNTY PUBLIC HEALTH; S' ERVTCES ENVIRONMENTAL HEALTH DIVISfON } 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201. E n PERMIT EXPIRES YEAR FR M D T 0 Q PC-I, r (Complete in Triplicate) Application 1a hereby made to San Joaquin County for a permit to construct and/or install 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 Joaquin County Public Health Services. D o � /z t1/ Job Address !/, City t Lot Size/Acreage Owner's Namddress lT�- q Phone Contractor Address42 JS (cense No32Jox�- Phone �- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR' OTHER ❑ Elonitoring Well EJ 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 (�(� 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing lr?7{Oomestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'I Public ❑ Other Fl Delta Depth of Grout Seal Type of Grout O I I Irrigation _Approx. Depth I I Eastern Surf a Soul Installed by Repair Work Done /8 Type of Pump j�� M.P. / Stats Work Done Wall Destruction ❑ Well Diameter Sealing Material a Depth ^ Depth Filler Isaterial A Depth ` ll TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No ,ephc system permitted it public sewer is available within 200 lest.) Installation will serve: Residence _ Commercial_ Other Number of living units: _ Number of bedrooms Character of we to a depth of 3 feet: Water table depth \ SEPTIC TANK O Typo/Mfg Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ Method of Disposal \\\y\\1 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size \ 1 FILTER SED CI Distance to nearest: Well Foundation Property Line C> SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 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 subcontracting 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 spplrc t call for MI required inspection*. Complete drawing onre rs side. Signed SignX / �rr�/J Title: ///� -e S Date: / FOR DEPARTMENT USE ONLY n — Application Accepted by Date b Area /1 Pit or Grout Inspection by ate Final Inspection Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services (�lJ 445 N San Joaquin, P O Box 2009, Stith, CA 95201 IF/E/JIp AMOUNT DUE ED REMITTED / rSH RR/E/C/1EIIVVED BY OA/T/�E y/' PERMIT'NO. • EH �;: (REV. /e,l C `, l^ IJ�sI I�J I / /-ITI L(/��/-! / ✓(Orr la.