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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PE_M T T E7CP I RTsS 1 YEAR rROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application in made in compliance with Bart Joaquin County Ordinance No. 549 end 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ` �"`� City S Lot Size/Acreage Owner's Narr►el//ttf Y�� PA-ej=4t> . ,1� Address �l,S3fl W. I Phone 7 OR Conlractor Sid 1Q'"'' Address License filo. Phone r� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER � ��n8 U J DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. RO L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION C i Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing LJ Domestic/Private Cl Gravel Pack. ❑ Tracy Type of Casing Specifications M Public 1-1 Other D Delta Depth of Grout Seal Type of Grout M Irripafion —Approx. Depth C) Eastern Surface Seal Instailed by Repair Work Done U Type of Pump H.P. State Work Done WIN Destruction O Well Diameter Sealing Material i Depth Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION n REPAIR/AOOITION 0 DESTRUCTION ED (No septic system permitted if public sewer is available within 200 feet.) _ 1 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 -SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal -� Distance to nearest: Well Foundation Property Line ^~ LEACHING LINE ❑ No, & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Site Number r SUMPS LI Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the worts will be done in accordance with San Joaquin county ordinances, state laws, and, rules and regulations of the Sen 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 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 must call for all required i-nsWtions. Complete drawing on reverse side. Signed S `""^' t Tltb: y�/ Date: R EPARTiNENT USE ONLY Application Accepted by Date _ r Area • �� \Z- Yfo v �� 1Z--?6 l7 0 Pit rota napection by�_ Data F Final Inspection by�- 4�^3 -f Oats Additional Comments: `Uca hon �`eL eche v . t-r n c vt K e �r — Applicant - Return all copies to: :SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 5�- .ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 ^A FEE AMOUNT OUE AMOUNT REMITTED CK t RECEIVED BY DATE PERMIT NO. INFO CASH C ^, . EH 13-24IREV I/a5I EH 14.26