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APPLICATION FOR PERMIT . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES v, ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EMIRE" YEAR (Complete is 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. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. -� Job Address ,L,rG!Ls' A _ IVE MW City Lot Size/Acreage„ Owner's Names �� '[ ddress Phone t Contractor Address rjLicgAse Na: Phone Al TYPE OF WELL/PUMP:r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring well C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE ��' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Weil Casing U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications M Public I-1 Other O Delta Depth of Grout Seal Type of Grout 0 It Approx. Depth Cl Eastern Surface Seal.,installed by 4 Repair Work Done U -IType of Pump' H.P. ,` State Work Done Well Destruction O ,W Well Diameter Sealing Material i Depth Depth-_. - Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRlADDITIONDESTRUCTION 0 1No septic system_permitled if public sews► is available within 200 feet.l Installation will serve: Residence_1< Commercial_ Other Number of living units: .,_. Number of bedrooms 5 Character of Sall to a depth of 3 feet: Water table depth SEPTIC TANK,.,Z%1ST'0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 0 T _ _ 'Method of Disposal ' tis Distance to nearest: Well Foundation Property Line r i LEACHING LINE No. & Length of lines 412_61 12 - Total length/size FILTER BED Cl Distance to nearest: Well�'r Foundation 'r Property Line «� - SEEPAGE PITS 11 Depth Size r Number SUMPS Ll. Distance to nearest: Well Foundation Property Line DISPOSAL PONDS .0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and f rules and regulations of the San Joaquin County Home owner or licensed agent's signature canities the following: "I certify that in the performance of the work for which this permit is issued. I shall not employ env person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring of sub-contracting signature cartifies the following: "I certify that;in.the.psrformance 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 for all �uirins Aions, Compl drawing on reverse side. ---t _ Signed Title: _, - Date: 3 r OR EPARTMENT USE ONLYct 'y 1 Application Accepted by 14 0.6� Data '• Area L Pit or Grout Inspection by Date Final Inspection by ate .2 i Additional Comments: Applicant - Return all copies. to: BANJOAQUINCOUNTY PUBLIC HEALTH SERVICES + f ENVIRONMENTAL •HEALTH DIVISION PERMIT/SERVICES [ 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE K III INFO AMOUNT OIJE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. H13-24if:EV.I/X5)1+� t �10 L+ 5 'p