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APPLICATION FORIT 4 SAN JOAQUIN COUNTY PUC ALT ICES SAN OAQ COI RTY-Ptm f 0 �1�': AL HEALTH D I V I� QUIN n 445 N- SAN 'IIOAQUIN, PHONE (209}468- �RONp��I ALT�j•$sft r' P O BOX 2009, STOCKTON, CA 95201 RMTH DNISION SPECIAL- PERMIT PERMS MIRES I YEARIFRAWDATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This } application is made in ec4liance with San Joaquin County Ordinance No. 51+9 and 1 62 and the Rules and Regulations of San r Joaquin County Public Neafflth Sery ces. Job Address City ✓ Lot Size/Acreage a4� Owner's Name Address ` 2'y Phone L 2 ~2-01 L" V � 7 1 1 � 3� �-. - - ..�----- �C/y�y=3 Phone=_ !. 'Ci)nlractor - Address --=�- -ieeIse No: TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT [-1 DESTRUCTION ❑ Out of Service Well ❑ f PUMP INSTALLATION ❑ SYSTE REPAIR 0 OTHER ❑ Monitoring Well C7 k DISTANCE TO NEAREST: SEPTIC TANK / 3 SEWE LINES DISPOSAL FLD. PROP. LINE FOUNDATION T ' - , AGRIC TUR OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL -RROBLEM AREA ONSTRUC I ,,��^^.*y�`�-- ❑ Industrial ❑ Open Bottom ❑ Manteca'�+o-- Dia. of Well Excsvatio8I14fa#ILIa El DomesticlPrivats ❑ Gravel Peck ❑ Tracy ^ Type of Casing Q i i"1 Public fel Other' Cl Delta Dep of Grout Seal ��Fcu rTf i N} I i Irrigation Approx. depth I I East n Surfedl Installed by �r+ Repair Work Done 0 Type of Pump H.P. State Work Done Weil Destruction ❑ -Wall Diameter: pealing terial A Depth i Depth ' "+�. "} 1Y111er Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION I 1 DESTRUCTION 1 1 INo septic system permitted if public sewer ism available within 200 feet,} ^^ Installation will serve: Residence— Commercial_ Other . 'Number of living units: Number ofrooms motif t Character of soli to a depth of 3 feet: 6JAter table pth Type/Mfg - SEPTIC TANK. 0 T opacity . Com manta PKG. TREATMENT PLT,❑ sat Distance to nearest: Well Foundation Property Line LEACHING LINE *'CI`"No-B_Letngth of lines Total thlsize FILTER BED ❑ Distance to aFesC--,Weil Foundation operty Line Y d 11 ( d SEEPAGE PITS l I Depth 2 hd- Size mbar ✓ I SUMPS Ll Distanee'io rest: Well oundstion J7 S Property Line DISPOSAL PONDS ❑ 0 I hereby certify that I have prepared thii application arid that the work wilt-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 eertifW8-1 following: "I certify ' ' fy thaf_in-the-perfbftance of the work fortwhich this permit is issued, 1 shall not employ any person in such manner as to become subject to-work mari'a compensation laws of California." Contractor's hiring 6r_sub-contracting signature certifies the following: ''I certify that in the performance-of•the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant st call;for`ON ired ins s ions. Complete drawing on reverse side. Signed Title: - ~t* Dille: �x Application Accepted by rDate tb Area } Pit or Grout Inspection by Date Final Inspection by Date /!r Adidkionsl Comments: Applicant 'Return all copies to: San Josqulo -County,'Public Health Services - I I Environmental'Healtb Permit/Services A.- j 445 N San Joaquin, P 0 Bo* 2009, Stkn, CA 95261 FEE I FO AMOUNT DUE AMOUNT REMITTE ASH RECEIVED BY OAT PERMET'NO l k l • EM 1124IREw.tied /r Err 11.20 I . V r