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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION .�OFy P 0 BO% 2009, STOCKTON, CA 95201 (209) 468-3447 Y R S �3� y� S_ �� „ _„y�� (Complete in Triplicate) App scat on is hereby rmde�Saa Joe ui County for n permit to construct and/or install the vork herein described. This application is made in couplience with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Satz Joaquin C Public Health Services. � [� Job Address ""`' City L/� .!" 2 Lot Size/Acreage 1P 0 -199 f ll.0 1 V Address c3() m Q k Q S � _ Phone Owner's Name . —I Gentle{for n9 Address 0 t License No.SI ? Phone i TYPE OF WELLIPUMP. NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK �._ SEWER LINES 't SZt r DISPOSAL FLD. F SSI PROP. LSNE--- FOUNDATION 't �r AGRICULTURE WELL ±-5—D OTHER WELL t �r PITS/SUMPS Fir INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS beat SOYirlS Y 30 r indusirisi ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil a ' 9 U Oomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L Public I:1 Other ❑ Delta Depth of Grout Seal Type of Grout Bynto dltt- obips CI Irrigation —Approx. Depth 0 Eastern Surface Seal Installed by f, - Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material Or Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 13 REPAIR/ADDITION M DESTRUCTION ❑ INo septic system permitted it public server is available within 200 lest.) Installation will serve: Residence.r.. Commercial— Other Number of 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.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wail Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 taws, 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 shelf not employ any person in such manner as to become subject To workmen'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&hall employ persons subject to workman's compensa• tion laws or Cal' nta." The appl' mu call for iol requir in clions. Complete drawing on reverse side. Signed Title: Date: FO D RTMENT USE ONLY Application Accepted by Date O Z ren ZI Pit or Grout Inspection by Data Final Inspeetl n by Datt✓ Additional Comment a: �3 Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ` 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE tAMOUNT REMMIITTED K EIVEO 9y DATE PERMIT NO. EM 1374 IRE v.1,%6) IC d2 Z4 // EtI'b7a V / Y��!