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• SIJ 1 u,( .. ' . /// � — .�; m.e �. APPLICATION FOR PERM I T 1 ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ;oh - Ici 1-7 ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or inatall the work herein described. This application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County PPujbliccHealthh Services..,� � �}�� Job Address it "50 5, ' x ." , ''�`'''COP City � Lot Size/Acreage Owner's Name Address �� l f ,. f-_S_ 0ME=9=•Ct51 0 Phone >+t Irt1e Contractor Address28LS License No. phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 92 6 t my s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, l FOUNDATION AGRICULTURE WELL OTHER WELL 10313 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ID Manteca Dia. of I g U Domestic/Private ❑ Grave! Pack 0 Tracy Typeof Ca in �eeifieeRierns l Public 1:1 Other 0 Delta Depth of t s Q irrigation Approx. Depth '0 Eaiterrt Surface Sod installed by r a� Repair Work Done U Type of Pump H.P. State Work Done + l f Well Destruction ❑ Well Diameter Sealing Material & Depth r Depth Filler Msterial i Depth TYPE OF SEPTIC WORK: .NEW INSTALLATION 10 REPAIR/ADDITION C1 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) 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 If SEPTIC TANK ❑ Type/Mfg -Capacity No. Compartments j PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 �1 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 applicant hust coil f r all r quir d inspections. Complete drawing on (eve se side: Signed t Title: 6f1 pate: [ �rdflPA-�ME�IiJT USE ONLY Application Accepted by Date 47 Pit or Grout Inspection by _ Date tnape tion b Date' Additional Comments:�:� _fes �y',t �v/1%�6 d�jf f� �c '4 Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 09, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PE�RtMJ NO. / EH 13,21(111 EV. EH.I.Zp /'� l