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F APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION I P O BOX 2009, STOCKTON, CA 96201 (209) 468--3447 R (Complete in Triplicate) Application is hereby made,to San Joaquin County fora permit to construct and/or install the,vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of San Joaquin County Public Health Services. Job Address 92 Lot Size/Acreage 445n/ - + Owner's Name Address Phone Conlract Addres ♦ ic6,si No. hon Com' .��TYPE.OF_WELL/PUMP: NEW WELL ❑� " WELL REPLACEMENT il= T T� DESTRUCTION ❑ Out of Service Well _Cl Miinitoririg�Wel7."""- PUMP INSTALLATION_ ❑ SYSTEM REPAIR ❑ OTHER ❑ U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE r f FOUNDATION AGRICULTURE WELL OTHER WELL 'PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ j Cl industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private Cl Gravel Pack '❑ Tracy Type of Casing Specifications M Public Cl Other ❑ Della Depth of Grout Seat Type of Grout M I►riUaf on Approx.,Depth ❑ Eastern Surlaca Said Installed by Repair Work Done ❑ Type of Pumps H.P._. - _State Work-Don*T� Well Destruction ❑ Well Dilmeter Sealing Naterial i Depth f Depth r L Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION 0 (No septic system permitted it public sewer is * W available within 200 feet.) installation will serve: "Residence • Commercial'-:— Other „Number of living units: �� Number of beds me 07 `x Character of soil to a depth of 3 feet'.Y Water table depth SEPTIC TANK Z U5T_ ❑ T r/Mf f yW g Capacity No. Compartments PKG. TREATMENT PLT. Cl f ; Method of Disposal 1 Distance to nearest: Well Foundation .. Property Line t t LEACHING LINE >�_No. $ Length of lines _ , YL�� Total length/size- FILTER BED Cl Distance to nearest: W81167 Foundation" _ Property Line lrr �.. SEEPAGE PITS Depth :�2= � Size L Number L.f SUMPS fLI Distanca_to_naarest: ,Weit. F i :Foundation Property Line DISPOSAL PONDS 10 I hereby cavity that I have prepfired-lhii'applicationand thal tlis work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County i i 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: "1 certify that in the'parfo►mance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for all required inspectionsCo!plate dr In ion rever Signed ' Title: +.T+` Dater 3 ----- FOR DEPARTMENT USE ONLY, .- Application Accepted by i Date iZ Area Z - or Grout Inspection by Date gr / Final Inspection by Oats j Additional Comments: I. Applicant - Return alt copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES " 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 r ! FEE AMOUNT AMOUNT REMITTED CK RECEIVED BY DATE PERM11'N0 INFO t r CASH ! EH g4.�{REV,i i 51 t o Z sz