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i APPLICATION FOR PERMIT k SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I� ENVIRONmmxTAL HEALTH DIVISION 1 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERH T_F"IRES I ygMFMM D TE ISSUED (Complete in Triplicate) Application is hereby made�to Ban Joaquin County for a permit to construct and/or install the work herein described. This application is made in campliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulationa oT San i Joaquin County Public Health Services. 1. Al _ City Lot Size/Acreage 3AC1 �-r Jab Address Address eA Iiol-:1 Phone Owner's Name 1 ) a ' -7 t Phone 6 �La �,�� ez• Address - Ar✓� License No. Contractor I TYPE OF WELL/PUMP: i� NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well ❑ ,� PUMP INSTALLATION ❑ SYSTEM REPAIR-0 OTHER ❑ Monitoring Well ❑ .,; i PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � DISPOSAL FtD. FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS � x I INTENDED USE TYPE OF WELL PROB -LEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 0 Industrial ❑ Open Bottom C1 Manteca Dis:of Welk Excavation Type of Casing Specifications ❑ GPack ❑ Tracy f-1 Domestic/Private - � I'1 Public Cl OltIher fl Delta Depth of Grout Seal _Type•of Grout \i 1. i I I Irrigation I`Approx. Depth I 1 Eastern Surface Seal Installed by ' H.P. State Work Done Repair Work Done ❑ Typal 01 Pump j I Sealing Material A Depth Well Destruction ❑ WelliDiameter Filler Material i Deptri � Depth l 1 t. ., TYPE OF SEPTIC WORK: NEW INSTALLATION sI i I DESTRUCTION l I (No ssystem permitted-if-public sewer is 11 available within 200 fest.I #nstallation will"ss+ve: itesidence-✓ Commercial .Other '�r x Number of living units: _ Number of bddroorns = .. _- --� _ - •<iI # '" : S d1 N 1> Y- r'�LA y V1laier table depth r Character of soil to a depth of 3 feet: __ � 4 SEPTIC TANK: _ G1❑ Type/Mfg __ _. _ . Capacity- No. Compartments f PKC TREATMENT PLT. I Method of Disposal "Distance to nearest: Well 1,19 0. :Foundation =�� Property Line No'6 Len th of lines Total length/size t'r LEACHING LINE g , I"' Foundation �92 — Property Line--'ZAP— FILTER 'ZAP — FILTER BED ❑ istanca to nearest: Weil _ a F SEEPAGE PITS I+I��P`epth r _Size Number I SUMPS Ll Dis nce to nearest: ' Well I -p �•. Foundation LSA Property Lina DISPOSAL PONDS ❑ til, 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lacus. and I { rules and regulations of the Sen Joaquin County Home owner or liuntlad 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 mohner as to become subject to`workman's compensation taws of California."Contractor's hiring or sub-contracting signature q y 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 i� tion laws of California." I b The applicant must call for all'hrequired inspections. Complete drawing on reverse side. Signed X_ Title: Data: ` FOR DEPARTMENT USE ONLY , r kation Accepted by Date �l, Ares or Grout Inspection by I! ate Finsl inspection by Date � Z 6_ �i2 Additional Comments: # µ 4 fl Applicant - Return iill Copies to San Joaquin County Public Health Services h EnvironmentalHealth Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 r c AMDUE AMOUNT REMITTED CK RECEIVED BY TE PERMIT N0. IFEE OUNT NF EH 13•I4 111Etr.r I EN 141-M - �/