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APPLICATION FOR PERMIT / p�y� = SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES /� �� I ( ENVIRONMENTAL HEALTH DIVISION = 445 N SAN JOAQUIN, PHONE (209)468-3420 *I P O BOX 2009, STOCKTON, CA 95201 /v PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sm Joaquin County for a permit to construct and/or install the vork herein described. This application is male in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Q� —P14City / Lot Size/Acreage Owner's Name Address ,/�-Q/.�--1� d� Phone � ! � r Contrac 23 License Q _ f°' Phones _ 41 V TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of 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 ❑ ddustn7al ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CsYDomastin/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public 17.1 Other. fl Delia Depth of Grout Seal Type of Grout 1 I litigation _Approx. Depth 11 East amh/y Surface Saul Installed by Repair Work Done ❑ Type of Pump�� H.P. r4— State Work Done �- Well Destruction ❑ Well Diameter Sealing Material.L Depth-. Depth Filler Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is Q available within 200 feet.) Installation will servo: Residence_ Commercial_ Other _ t. Numberof living units. _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ` PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to dearest: Well Foundation Property Lina 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, state laws, and rules and regulations of the San Joaquin County " Homme 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 Ixecome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature unifies the following: "I cavity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa. tion lave of California." The applicant must 1 II required i tions. Complete drawing on re ae side. �7 _ Signed K AP4 Title: —� Date: /� � FOR DEPARTMENT USE ONLY /- r Application Accepted by C-f C/V- 'Jl�'V.�O�'-„ Date !4 Q,, / - Area PH or Grout Inspection by Date Final Inspection by f/V 1f Data D A-�3 v Additbral Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services r. 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO_ AMOUNT DUE AMOUNT REMITTED I C SH RECEIVED BY DATE PERMIT NO. . EHEM 111431a11aEV.lr x sl n.(� `,�[�- o% . o% 3447 �' -9'9 93 -j.S3 q3 .i0 �