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cu•.r` s APPLICATION FOR PERMIT �+ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �j' ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95204 NJDUJ�rru . (209) 468-3447 � PERMIT , YE" ORQM PAJE ISSUED 1 (Complete in Triplicate) Application is 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 ��eeu_n�t,}'�Q dinance No. 549 and 1662 and the Rules and Regulations of San J�Joaquin County Public Health Services.SA"lf- rWzet 1 qS-3'L0�.0 kob Address .� � � f V E- City 57-C12 P-1 Let size/Acreage s Q KQwner'a Name 4 r, s �- !`�S Address Ao h- (for tk 4"Z Phone Phone 5 f x- onlractorC w' .fflMCr �Address P License No. Z Z7 Phone T'YPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Kell ❑ , 4 PUMP INSTALLATION 1) SYSTEM REPAIR ❑ OTHER ❑ Monitoringy441_[_- DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL,D. ._PROP.. LINE N FOUNDATIOAGRICULTURE WELL t OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f-} Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia, of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ID Public I'1 Other 0 Delta Depth of Grout Seal Type of Gout M Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by " Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Suing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR7ADDITION 0 DESTRUCTION INo septic system permitted if public sewer is J available within 200 feet.l installation will serve: Residence^ Commercial_*L-_ Othet �. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: i 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 t i FILTER BED ❑ Distance to nearest: Well Foundation Property Uria SEEPAGE PITS 11 Depth Site ''" Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby canny 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 — - "" S Home owner or ticensed agent's signature certifies the following: '14 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 work man's;compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- tion laws of California," a The applica=or all r qu' inspections. Complete drawing on,reverse side. — Kigned X — Title: >�C Date: Z f 7 DEPARTMENT USE ONLY Application Accepted by Date\Z Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 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 AMOUNT DUE BUNT REMrTTEO CK RECEIVED BY DATE PERMIT'NO. INfO �jCASH lel . EH 14-a INEV.1/'951 ,aa I d� r 4 1 -4 1-72 LF EH 3�•2e WX