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APPLICATION FOR PERMIT ' �Q,v ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 MAY 9 ig�1 (209) 468-3447 ENVIRONMENTAL HEALTH PERMIT EXPIRES I RM1T/SERViCFR S (Complete in Triplicate) Application is hereby msde,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in acupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. _ f Job Address 12� 14U: City Lot Size/Acreage Owner's Name Address Phone Contractor �-^� Address 1-6 490,ZZ&, '9530!5( License TYPE OF WELLIPUMP. NEW WELL ❑ -WELL REPLACEMENT (7 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION P--' SYSTEM REPAIR LSF OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL T OTHER WELL PITSISUMPS .� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1.1 Ind rill ❑ Open Bottom ❑ Manteca Oia. of Well Excavation Dia, of Well Casing f omeatic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications ❑ Public 1.1 Other ❑ Delta Depth of Grout Seal Type of Grout CJ Irrigation __,.Approx. Depth ❑ Eastern . Surface Seal Installed by k Repair Work Done 0 Type of Pump H.P. gnL&= .State Work Done f Well Destruction 13 Well Diameter Seiaing Material & Depth DepthFiller-Material-ii;Depth TYPE OF SEPTIC WORK: NEW INSTALLATION O—REPAM/ADDITION Ci DESTRUCTION G INo septic system permitted if public sewer is :a available within 200 feet.) Installation will serve: Residence Commercial. Other Number of living units: Number of bedrooms rti Character of soil to a depth of 3 feat Water table depth J SEPTIC TANK: ❑ Type/Mfg Capacity No. Compartments 4 PKG.STAEATMENT PLT, 0 R'� Method of Disposal Distance to nearest:-.,_ Well Foundation Property Line LEACHING LINE ❑ No. $ Length of lines i - Total,length/size- FILTER BED [:1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth 1 Size 'Number SUMPS L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ M F I hereby certify that i have prepared this application and that the work will be clone in accordance with San Joaquin county ordinances, state laws, and ruins and regulations of she San Joapuin County Nome 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 wdrkman'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." ., Y The applicant m Mr all requir d inspections. Complete drawing on reverse side. FSigned X ____- Title, Date: 4^ FOR DEPARTMENT USE ONLY 6 Application Accepted by Date Area-An- Pit or Grout Inspection by Date Final Inspection by ate 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 95201 r, FEE AMOUNT DUE AMOUNT REMITTED C1( # RECEIVED aY DATE PERMIT'NO. INFO CASH EH 13.24 IREV.iiw6i �� EH 142e �� VV I