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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONXENTAL',HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR-FROM -DATE ISSUED (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 County Ordinance No. 5 9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. F Job A.,. 6 4 79 City Lot Size/Acreage Owner's Nant* QVA77dress _Lit_ Phone + Contractor l`�.. Address 17 License No.•1 1t�?3? Prion TYPE OF WELL/PUMP! N WELL O _ WELL REPLACEMENT-n 'DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _WfENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dia, of Welt Excavation Ois. of Well Casing _ _f C:1 Domestic/Private 0 Gravel Peck ❑ Tracy Type of Casing Specifications f•1 Public 171 Other n Delta Depth of Grout Seal,, Type of Grout I i Irrigation / __ Approx. 0 h I Eastern Surface al Installed by Repair Work Done !'> Type of Pump v Q, H.P. State Work Done Well Destruction O Well Diameter Sealing Material 1 Depth Depth Tiller Material i Depth j r� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is- available within 200 feet.l Installation wifi serve: Residence_ Commercial_ Other Numbar of living units: Numb r of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT.❑ Method of Disposal ` Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of fares Total lengthtsize t FILTER BED C7 Distance to nearest: ndation Property Line Z SEEPAGE PITS 11 Depth Sire Number SUMPS L1 Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ I h*reby certify 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 Romaowner or I' "nit's signature certifies the fopowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ arty n in sueh as tc become su to workman's compensation taws of Califorrue." Contractor's hiring or sub-contracting signature eartlfisa the allowing: "I fy that in p*rfor n of the work for which this pxrrrt is issued,I shall employ persons subject to workman's comperes tion laevs Calif nla." The a ant t c r all r C pteIs drawing Signed .60' Title: ~IJ/! Date: FOR DEPARTMENT USE ONLY Application Accepted by Aa 4, d t,p(Z[w,.+ Date Area Ph or Grout Inspection by y Date 'Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVEo By DATE PERIAWNO. . EH132/IRV.1/r.e EH t1-0 F