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x` APPLi CATI ON FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SRRVIC ENVIRONIENTAL HEALTH DIVISION JP O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 AP 18 Af%n YEAR PROM DATE 111�IRONMENTAL HEALTH (Complete in Triplicate) RR rr`� jj�� Application is hereby made to San Joaquin County for a permit to construct and/.or install teeEaR1Ti��'1i1 M§ed. This application is made in owwliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 31-S" ( Job Address' }-^I r Chy _ ��_ Lot Size/Acreage Owner's Name _ 1 f��1 U�ff PC � Address InPhone I Conlrac Ior L,r Address 3 �'.� License No. �657�f Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ 3. SYSTEM REPAIR OTHER ❑ Monitoring Well G7 DISTANCE TO NEAREST: SEPTIC TANK,_ SEWER.LINES t DISPOSAL_FLD. PROP. LINE - FOUNDATION AGRICULTURE WELL-'. OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROOLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ©-Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private C7 Gravel Pack 0 Tracy Type of Casing Specifications Ci Public El Other i ❑ Delta Depth of Grouti Seat Type of Grout �j Irrigation i Approx, Depth ❑ Eastern Surface Seat Installed by Repair Work Done U Type of Pump�. (r� H.P. . f State Work Done Well Destruction O Well Diameter I k j.l Sealing Material i-bepth Depth_ _.c2e'I;_ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION C'f -DESTRUCTION I=t INo septic system permitted if public sewer is P available within 200 lest.} Anstollation-will serve: _Resid'ence Commercial__,__. Other Number of living units: Number of bedrooms ;F, �' Character of soil to a depth of 3 feet: *� ,,_ Water table depth SEPTIC TANK 0 I Type/Mfg 1. Capacity �S fE`t`� No. Compartments PKG. TREATMENT PLT, ❑ ?` ,,.Method of Disposal Distance to nearest: Well Foundation.fit i `" Proper't'y,..Line I LEACHING LINE CI No. A Length of lines f Total length/size FILTER BED n Distance to nearest: Well FoundatioAl I Property Line_' r SEEPAGE PITS I I Depth ? Sire i r Number __i:__SUMP_S,,; R._L1—Distance to nearest: Well Foundation_t } - Property kine DISPOSAL PONDS ❑ " f I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state I ws,.,and } rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifiea 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 Calilornia." Contractor's hiring or sub-contracting signature certifies tha full g: "1 certify that in the performance of the work for which this,permi�is issued, I shall employ persons subject to workman's'compensa- tion { tion laws of C lifo nla." i The appli t st call for all r fired inspe 'on -Gomplete drawing on rev r side; Signed .Title: Date: i `° ..FOR DEPARTMENVUSE ONLY Application Accepted by '^ l Data Area . /� Pit or Grout Inspection by Date Final Inspection by Da4e s t Additional Comments: j I Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` _ENVIRONMENTAL-HEALTH-DIV ISIOW-PERM IT/SERVICES �- 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 9520{lrFEEa` 1 i INFO AMOUNT DUE f AMOUNT REMITTED.' =f SH RECEIVED 8Y DATE PERMIT NO. + EH14•24 IREV.iiM31 R yrs, EH",4•2e III P ! � - �„ t A