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! APPLICATION FOR PERMIT ^" I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ELiVIRONYENTAL HEALTH DIVISION P'O $O% 2009, STOCKTON, CA 95201 (209) 468-3447 ({frf fPisluda (Complete in Triplicate) - k 8 Joaquin County dor a pe . 'Applleatltrni•fi hereby made to rmit to construct and/or install the work herein described. This application Iii aside in co4llance with Bon Joaquin County Ordinance No. 549 and 1862 and the Rules " Regulations of San Joaquin Job Add CouDty:IPublic Health Services. 1 I44 Is- .� Ptei+ e r City ,/1 6&rnp,.� Lot Size/Acreage:��_ fan ! t� Owner's Name �, N~ ' b0hdn Address s cryyp Phone f Contractor L ',�I.f Address 1 n Rt1✓ l N 5 + License No. -Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ . Monitoring Well C1 ` •^�1STA'NCET6 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 Ll InUuatrial i ❑ Open Bottom ❑ Manteca Dia."of Will Excavation Dia, of Well Casing U Dormstie/Private ❑ Gravel Pack ❑ Tracy ,Type of Casing i Spedilica[ions a1 p1K 1:1 Othaf ❑ Delta Depth of Grout Seal Type of Grout � ❑ Infgauon _.Approx. Depth ❑ Eastern Surface Seal Instilled by i i _.. Repair Werk pons O Type of Pump H.P. State Work Done Well Destruction O Wall Diameter Sealing Material i Depth _ Depth +i Filler Mateepth Material i D _ � - ,',U96EAF„S.EP_TIC WORK; MEW INSTALLATION O REPAIR/ADDITION DESTRUCTION U Ileo septic system permitted if puWirsnwm'is evaiiable within 200 feet.) installation will serve: Residenga..`Commercial.__-.Other .-- - --�- •^ + Number of living units: `Nu'rnber of bedrooms 3 '1 ,'-•• / - � beat r t:. is depth + Character of soil to a depth of 3.feel: % _ y '�et _?- -SEPTIC TANK F✓Type/M�p• =`f!.-,nr dt_ Capacity 4. � +'Ne CornWrtrrxmts, PKG. TREATMENT PLT.❑ .� +'�Mathod of Diapotal Distances to nearest: Well"=Foundd_fl '•{ P, pony Line �! - I "{ LEACHING LINE ace'/No. 6 Length of lines.. Pe� TLolel length/size A.(% FILTER BED ❑ Distance'to nearest: an. Foundation . Property Line SEEPAGE PITS I I Depth __Si:e - ��N••u--rPhor .r / SUMPS v'Distance to nearest: Well JseJ Vc� n`dation ..y PrdpeM Line — f f DISPOSAL PONDS 0 -f ' I hereby comity, that I have prepared this application and that the work will be done in accordance with.San Joaquin county ordinances, state laws, or rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify Thal In the performance of the work for which this permit is issued, 1 shall n. employ any person in such manner as to became subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting s19naiu ,. certifies the following: -I certify that in the perAmmance of the work for which this Permit is issued,I shall employ persona subject to workmane compons tion laws of California." i I The applicant must call for all required inspaptiono'Complete drawing on reverse side. t N,_f •'�, 1 t Title: 6 5 .— I bate: Signed f_ FOR DEPARTMENT USE ONLY, ' A ion AccsP by ._ Dsle Area In ethn by Date - J/ Final Inspection by ata LLL Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ENVIRONMENTAL REALTN_DIRISION.PERMIT/SERVICES--;�------- JOAQUIN, P O BOX 2009, STOCKTON. CA 96201 i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE `s PERMIT NO. vel j EN 1324 INKS i;xar S i L <;-,y , rX .4M PP