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i APPLICATION FOR PERMIT 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESNI. 11�4 ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 l') (209) 468-'3447 j YEAR PRQM DATE I20UED (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 is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San !!' Joaquin County Public Health Services. I itob Address 70 7 r All City iq4 MPO Lot Size/Acreage J -- n� -• �IOwner's Name �ru 2Z'?i f Address t/70( ✓`*sfGH d Phone r Contractor 0tt1C Address . License No. Phone TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well (7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing O Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications ❑ Public I'1 Other 0 Delta Depth of Grout Seal Type of Grout M Irrigation Approx, Depth ❑ Eastern Surface Saul Installed by Repair Work Done L] Type of Pump H.P. State Work Done Well Destruction O Weil Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW'INSTALLATION 13 REPAIR/ADDITION 0 DESTRUCTIONN INo septic system permitted if public sewer is 11� available within 200 feet.) 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 0 Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT, Cl Method of Disposal Distance to nearest: Welt Foundation Property Line I I LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth 1Sire Number SUMPS L1 Distance to nearest: Well Foundation .Property Line 1 lI 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, and 1 rules and regulations of the San 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 subcontracting signature eenifies 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 requir d inspections, Complete drawing on reverse aids. �� o �CSigned x Pte'- .• _ - D Title: a" � 2 � Data: � OR P -ONLY J c Application Accepted by Ol �srAw.v. ^ Date J Z b y 1 Arean Pit or Grout Inspection by Data FineE Inspection byll*'amu- fJ Date L_/ � Additional Comments: Applicant - Return all copies 'to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95241 CK INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVER BY DATE PERM17 N0. . f 13-241PFV.+ ws1 ENA-20