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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAINHEALTH DIVISION 445 N SAN JOAQUI PH b 468-3420 P O BOX 2009, STOC , RO NAMgMTHMMICU DIVISION PERMIT EgPIRES l FRHTT (Complete in Trip lieRtYL"`'141" � �1� Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. �,J�1 /N Yf�'; ��1/Z>� / mac __ ._ City �'�! Lot Size/Acreage Job Address _ r� Address Phone ct�� Owner's Name�._ _ Contractor + dress U License NoL , ,none s �" l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ out of Service well 1-1 i OTHER ❑ Monitoring well (3PUMP INSTALLATION ❑ SY EM REPAIR 13 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS P L FLD. PROP. LINE FOUNDATION AGRICULTURE LL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CO UCTION SPECIFICATIONS 4 C1 Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing Ty of Casing— Specifications n Domestic/Private ❑ Gravel Pack ❑ Tracy 9- , , i'l Public (-I Other teType of Grout r{ De th of Grout Seal I I Irrigation .... Approx. Depth I ] Eastern S WPM" -- H.P. Repair Work Done U Type of Pump Weil Destruction ❑ Well Diameter Sealing terial i Dept ( �1 t Depth biller MateriPER al INSTALLATION I 1 REPAIR JA PITION I DESTRUCTION I l iNo septic system permitted if public sewer is TYPE OF SEPTIC WORK: NEW available within 200 lest.) (� I Installation will serve: Residence Commercial— Other y y Number of living units: Number of rooms, Character of soil to•depth of 3 fest: Water table depth I— Capacity No. Compartments l SEPTIC TANK i-W--f7 Typa/Mfig--- - - PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation ' Property Line LEACHING LINE Cl No. 11, Length of linea t � �#`� otelrlengthlsize - FILTER BED C] Distance to nearest: 'lr Qation Pr pe Line + SEEPAGE PITS 11 Depth VLASize N mber f SUMPS Ll Distance to nes est: Well V d Foundation Property Lin �-+- IV 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,i nd i rules and regulations of the San Joaquin county ,. Home owner or licensed agent's signature candies the following: "I certify that in the performance of the-w or 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 subcontracting signature certifies the fallowing:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's componss- tion laws of California." # The spplicsn ust call f requin"pilons. Complete(drawing on reverse side: ' � � Date: Signed Title: FORiDEPARTMENT ilSE ONLY -- .' 1QS�3 Gam .. Date.`3- _ Area Application Accepted by � r or(trout Inspection by EMALTHISEMMg .,P AL HEALTH DIVISION f Additional Comments: Trr Applicant - Return all copies to: San Joaquin Co b 1 1 i ALT vironmdntal Health Permit/Services 5 H San Joaquin, P O Box 2009, Stkn, CA 95201 + i FEE AMOUNT OVE AMOUNT REMITTED Clt RECEIVED 9Y JMTE PERMIT'NO. i INFO . fM 11.28 Ev.„e Si I / t EM 14-28� 7 6