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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �� rD0 AW�r P O BOX 2009, STOCKTON, CA 95201 (209) 468--3447 PERHIX EXPIRES 1 YEAR tROM DATE ISSUED (Complete in Triplicate) Application In 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 Count Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. <fJ-Z:744j7--S Job Address frT T r City Lot Site/Acreage Owner's Name Address /492F11541 72P91- Phone 317 Contrattor y Addressd/,,2,Q�G�1�' License No. Phonr! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications Q Public -1 Other ❑ Delta Depth of Grout Seal Type of Grout 0 IffiUation _ Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well OestructronK Well Diameter �i__ Sealing Material & Depth F/t-� ,r�/Ij,t/ P z pth Filler Material i DepthAV-Za Al TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Ll DESTRUCTION i✓I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence r. Commercial_-•__, Other Number of living units: Number of bedrooms Character of Boil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.f<1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines - Total length/size FILTER BED n Distance to nearest:- Well- Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Wel Foundation Property Line DISPOSAL PONOS Cl I hereby certify that I have prepared this application and that the work wilt be done in'accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County - t 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: "l certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Iowa of California." The applicant m requir ns. Complete drawing on revers oda. r.r Signed X Title: bete: Z �/ OR DEPARTMENT USE ONL Application Accepted by Date p' ` Area Pit a lou tion by v` _ Date 2��T Final Inspection by _ _ ate Additional Comments: r l• e •>-� a Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SER 3 ENVIRONMENTAL HEALTH DIVISION PEW /SERVICES 445 N SAN JOAQUIN, P O BOX 2009, -STOCKTON, CA 95201 INFO FEE / OUNT DUE AMOUNT REMITTED CASH K 11 RECEIVED BY DATE PERMIVNO. EHtI24IttEV.iinsl L I