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APPLICATION FOR PERJdIT SAN 'UIN COUNTY PUBLIC HEALTH�VICES ENVIRONMENTAL HEALTH D I V I S�_. 4%5 N SAN JOAQUIN, PHONE (209)468-5420 F O BOX 2009, S. 00KTON, CA 95201 P •Pi T E P T ziES I ` FAB `+'RQM FATE I.589 (Complete is Triplicate) Application is beret w_4e.to Ban Joaquin County for a permit to construct and/or install the !Fork herein descrf.bzd. This applications is mule in c-W_11ence with San Joaquin County Ordinance No. 549 and 1862 and the Rulers r.aD. Regulations of `Ss.0 Joaquin Cananty Putaa.ic Health S,rvices. Job Address es—, C: - y��:L '� S='` '�'"r Lot Size/Acrrage O Owner's Name �t2f _�. � �"�"Rdtiress T'� y� 197 � Ph� oGdL_.�_ __ _t•_L_ hes [; ,/�76C � / jlcen�a 12?(& Ph��Contractr / Add � f ik? � + '�L TYPE OF WELL/PUMP: � EW WELL O WELL REPLACEMENT CI DESTRUCTION O�t.ofof `ertviet '+ell Cl PUMP INSTALLATION O SYSTEM REPAIR O OTHER O,5tl�lon12or1tys, Wel.l.sl-, s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINT FOUNDATION AGRICULTURE WELL OTHER WELL- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA O If Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ^' Dia. of Well Cuing Cl Domestic/Private Gravel Pack 0 Tracy Type of Casing_ 2 /f a L Specifications •--.- i'1 Public Cl Other n Delta Depth of Grout Seal •t' Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed Repair Work Done U Type of Pump H.P. State Work Dona _ Wed Destruction ❑ Well Dismeeer Sealing Material i Depth s � • Dci;th __ Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will se Residence ommercial _ Other Number of living unit ,�_� ',•uummbe of bedrooms Character of soil to a w of 3 f"t: Water table depth SEPTIC TANK O T Mfg Capacity No. Corr,partrnents PKG. TREATM PLT. O fvie:P:od of Ditpoa3l Distance to nearest: Well Foundation Property Line LEACHING LINE No. gth of lines Total length/size FILTER BED tans to nearest: Well Foundation Property Line SEEPAGE PITS I Depth Size Number SUMPS stance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this ation 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 Home owner or licunsod agent's signature oenifiss the following: "I certify that in the performance of the work for which this perrnt is iss;oo1, I shad not employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or suaconracting signature candies the following: "I cartify that in the portormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call tor ad required inspections. Complete drawing on reverse side. Spited Title: C Iro Date: FOR DEPARTMENT USE ONLY U Application Accepted by Dau ` '�� Area • O' Ph or Grout Inspection b-Jy2 ,f� Date Final Inspection by Oate Additional Comments: ad.4moviZ1, Applicant - Return all copies to: San Joaquin County Public Health Services Savironmental Health Permit/Services 448 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNNjT DUE AMOUNT REMITTED CASH CK if Q�RECEIVED By OATE�/�7 PEERM17 N0 71 . EM 14.7/3 t11Ev N t�- . V t� " • ' \ cf.��' 13 `TJ—l E