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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE&: ENVIRONMENTAL HEALTH DIVISION "' s t 445 N SAN JOAQUIN, PHONE (209)46$-3420 Egg_ P 0 BOX 2009, STOCKTON, CA 95201 �? e.1v ef- }i ]PERM T EXPIRES 1 YEAR FROM D T S �,�)0AQtV 16V!�V I;, .•-z � - +t (Complete in Triplicate) ENV1RG�j4' Egr 7h SL licatioa is here tmde,to San J � A� by Joaquin County for a permit to construct and/or install the work herein d�e'scriDed. This application is made in compliance with San Joaquin County Ordinance No. 549 end 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Q Job Address Z2 3 / J ' "�� City�4 Lot Size/Acreage /Z? ac,U(,e u A #r Gly 759-31674 Owner's Name .ii�gs,s Phone Contlaclorddress License No. rPhone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service Weill❑ PUMP INSTALLATION ❑ SYSTEM REPAIR `,4A,_-� OTHER ❑ itoring Yell 0 DISTANCE TO NEAREST: SEPTIC TANK L �� SEWER LINES DISPOSAL FL L E FOUNDATION _AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial O Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications I'1 Public - El Other � n Delta Depth of Grout Seal Type of Grout � I I Irrigation ____Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diametei Stealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION [ I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence— Commercial— Other r Number of living units: Number of bedrooms Character of 800 to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal ! Distance to nearest: Well Foundation Property Line a. } LEACHING LINE ❑ No. b Langth of lines Total length/size y FILTER BED 0 Distance to nearest: Well Foundation Property Line f SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to nearest: . Well Foundation Property Line 1. 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, slate laws, andY 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 I certifies the following: "I certify that in the performance of the work for which this permit is issued, I @hail employ persons subject to workman's compensa- tion larva of California." The applicant st call.for all u' spektions. Complete drawing an Leverfse sidg. Title: l/�" Signed ' - Data: FOR DEPARTMENT USE ONLY Application Accepted by Data �,r� �l_2 Area /- Pit or(trout Inspection by Date Final Inspection by k Additional Commems: i Applicant —Return all copies to: San Joaquin County Public'Health Services Environmental Health Permit/Services �Jll 445 N San Joaquin, P O Box 2008, Stkn, CA 95201 I FEE IAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO. . EN 1321(REV.1/K 51 �5,-I�a /-��-- .Eli 114@ I ,