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M APPLICATION FOR PERMIT de SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION f P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXP-MES 1 YEAR IrROM DATE ISSUED ,' •.� (Complete in Triplicate) ,3 Application ie hereby titnde,to Says Joaquin County for a permit to construct and/or install the work herein,describea. This application in made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Se vices. Jab Address�✓ ��7 �v � 1 City OVE Lot Size/Acreage �4 `'r Owner's Name Address Phone 1 Contracto AddressA&.Zy_�-nse No.4Z,!VJ&P`hone9 . TYPE OF WELL/PUMP. NEW WELL ❑ _ WELL REPLACEM T F-1 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ w SYSTEM REPAI� OTHER ❑ Monitoring Well [1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE 6r-- W ELL PROBLEM AREA ;-CONSTRUCTION SPI CIFICATIONS � n Industria ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing �omastic/Private C] Gravel Pack - 7 Tracyr..- 4petof�6asing- - -- -•- —Specilications °• C) Public I:1 Other \.\ , p Delta: l :Depth of Grout Seal Type of Groul\ ( y�� CI Irrigation -.Approx, D pth R�� 5u ca Seal Installed by ^` Repair Work Done U Type of Pum —_ t or one 4� Well Destruction O Well Diameter!! ing Material i Depth f Q Depth 111 Filler Material i Depth TYPE OF SEPTIC WORK: NEW JNSTAILATION.J-)._-REP_AIR/ADDITION:CI...DES TRUCTION-0-4-No-se tic-system, ermined if _ p p public sewer is A available within 200 lest.l Installation will serve: Residence {Commercial Other q Number of living units: Number of bedrooms ; t Character of soil to a depth of 3feet: I Rin at table depth r SEPTIC TANK O Typri/Mfg Capacity No:.Compartmants PKG. TREATMENT PLT. D i fu{tiihod of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.,& Length of lines Total length/size } FILTER BED n Distance to nearest: Well Foundation Property Line J SEEPAGE PITS 11 Depth s Size Number_ SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ " 1-hereby certify tharl hove-prepared this-application-and-that-the work-will be done-in-accordance-with San Joaquin-courity-ordinances,.-state-laws;-and- J rules and regulations of the San Jo'quin 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 employ any parsor�in such manner is to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify theiliri the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." i The applicant must call for nspb.ckons. Complete drawing o side. Signed X Title- Date- FOR a Date: FOR DEPARTMENT USaE'ONLY 1 Application Accepted tr '. y Date i Area / Pit or Grout inspection by Date Final Inspection by J Date J Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 1� I 945 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 FEE CX 0 INFO AMMMO`UUNNTJ DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH t4•241REV,iix61 �V�[/°' �� \ �� ©� •+�