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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ""�'"' EjNVIROMdENTAL HEALTH DIVISION " 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 E%PIRES I YEAR FROM D TE 14SUED r cev�Jpi mplete in Triplicate) Applictition is hereby medefto $an qu Coun y for a Permit to construct and/or install the work herein described. This application is made in ec4liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job AddressON Z&os�-��-,8 _ City C V Lot Size/Acreage Owner's Name JOVAI eosE } Address .li vNEvay Phone �,9Sc 6rc t awo¢ /n!a%Srw-,;f, Contractor Addressd License No. 2492> 2—Phone s/O TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR M OTHERMonitoring Well n DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLO. PROP.`�LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications_._ Il Public 1-1 Other n Delta Depth of Grout Seal �� Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by /! Repair Work Done ❑ " Type of Pump H.P. State Work Done, 4 Well Destruction ❑ Well Diameter -Sealing Material i Depth Depth Filler Material R Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of tiering units: Number of bedrooms • Character of Soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. 6 Length of linea Total length/size < FILTER BED ❑. Distance to nearest. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Cl 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, slate laws, and rules and regulations of the San Joaquin County \ Home owner or licensed agent's(signature certifies the following: "I certify that in the performance of the work far which this permit is issued, I shall not t employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring of 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 applicant st call for all req ed inspections. Complete drawing on reverse side. S'gled Title: Date: '�� QEscv 6-600v- FO FD pE RTMENT USE ONLY ` Applin n Accepted by Pit or Grout Inspection by Area Date Final Inspection by Date i Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Hox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY INFO A H DATE PERMIT'NO. 1W 3--o tiH tr.]a .- k