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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201., (209) 468-3447 PERMIT YEAR EROM DATE (Complete in Triplicate) Application le hereby made,to Sao 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. / JOb Address City r Lot Size/Acreage 4&S-102 �Qwner's Name Address \\'tiContractor� �1 _ Address JL24" License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ ELL REPLACEM T ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM PAIR O OTHER ❑ Monitoring Well [7 DISTANCE TO NEAREST: SEPTIC TANK SEWER Ll 5 DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTU WE OTHER WELL PITS/SUMPS .r INTENDED USE TYPE OF WELL PROBLEM AREA CO TRUCTiON SPECIFICATIONS 11 Industrial ❑ Open Bottom ❑ Manteca D' . f Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack ❑ Tracy ype IF Casing Specifications M Pubfic 1-1 Other ❑ Delta Depth f Grout Seal Type of Grout C1 Irrigation Approx. Depth ❑ Eastern Surface oul Installed by Repair Work Done 0 Type of Pump H State Work Done . Well Destruction ❑ Well Diameter sling Material Depth Depth Filler )Material i Npth TYPE OF SEPTIC WORK: NEW INSTALLATION 0. REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ZCommercial^ Other Number of living units: _..]_. Number of bedrooms 5 Character of sail to a depth of 3 feet: a Water table depth Q SEPTIC TANK Type/Mfg F R_LAp_T, L "I Capacity ,001a1W No. Compartments a C PKG. TREATMENT PLT, 0 ! I.9 Method of Disposal L 0 -0 Distance to nearest: Weil 00 Foundation Property Line &ar LEACHING LINE kr*�No. B Length of lines .Z RO_r _ Total length/size FILTER BED V Distance to nearest: Well �0G Foundation _ZO / Property Line SEEPAGE PITS W Depth Si:e /I Number .3 b SUMPS Ll Distance to nearest, Well /7-0 `Foundation _45_ Property Line DISPOSAL PONDS ❑ ��tereby 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 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 n employ arty 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." ,Fhe applicant must call for all required in c ' ns. Complete drawing on reverse side. p Signed Title: _ Date: 312 7 F ARTMENT USE ONLY j Application Accepted by aC` Date � Area PI or Grout Inspection by ate �/ � final Inspection by Dats 9 7 Additional Comments, Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO MOUNT DUE A AUNT REMITTED CK 9 CASH RECEIVED BY DATE PERM11,NO. /� 60I X07 ?�" -[ 4 (��'©`fes4W