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APPLICATION FOR PERMIT a h SAN JOAQUIN ENV I ONMENTAL HELALT DIC HEALTH I S ON V I CBS�� P O BOX 2009, STOCKTON, CA 95201 A 0 (209) 468-3447 �' // (�� PERYIT .ESPIRES 1 YEAR_FROM AA $S � 1, "'12 (Complete in Triplicate) ,t Application is hereby made.to San Joaquin County for a permit to construct and/or install the work hereit5-described. This application is made in emwliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulit dtre of San Joaquin County Public Health Servicea.�p-7 S , r n !'aT t KUt fo�f/ Job Address Sri ' �rat1 Orn- >A �• City r_ Lot Size/Acreage Owner's Name &,0_,,P;qJAdd(ess Q ? Ing -4r1_• Phone irffT 6710 Contractor `a lWs fut- Address _307 } /'C I IYy%r� License No.�1I?�Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION put of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well 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 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing U Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications ❑ Public I 1 Other D Delta Depth o! Grout Seal pe of rout 09I-hp !Q" DW0 Irrigation Approx. Depth n Eastern Surface Seai Installed by 1 Repair Work Done Ll Type of Pump H.P. State Work Done Well Destruction Well Diameter 1P Sealing Material 6 Depth Depth Filler Material i Depth Pt ( ( 1 L L �� TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIR/ADDITION Cf DESTRUCTION 0 (No septic system permilted if public sewer is available within 200 leet.l Installation will serve: Residence—. Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth �. SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, C1 Method of Disposal Distance to nearest: Well Foundation Property Line Z LEACHING LINE ❑ No. 8 Length of lines Total length/sire FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby comfy 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 Home owner or licensed agent's signature certifies the following: "I 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 workman'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 shall employ persons subject to workman's compensa- tion laws of California." The applicanA�fl f ra ednspections. Complete drawing on re Signed X Title: Date: FOR DEPARTMENT USE ONLY /� Application Accepted by Date/ Area �L Pit or Grout Inspection by I/ Date Final Inspection by Dets 61/2614?` Additional Comments: �I " Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O SOX 2009, STOCKTON. CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EN 13•24 IRfV.+i Ks) D 0.�-[fys— ('1 1 EH 3�.2e CT'\J