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APPLICATION FOR PERMIT ; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P o BOX 2009, STOCKTON, CA 95201 MAY 9 (209) 468-3447 ENIVi ONMENTAL HEALTH RMIX MIRES YAR FROM PATE PERJ'V?11_/5E1 V10ES (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 !e made in ccuPliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ia- },24 City^, Lot Size/Acreage I Owner's Name Address Phone i i I ,4 Address 0 O Conlractor�r�J!�� License No. Phone F TYPE OF WELL/PUMP: NEW WELL, O_ :, WELL REPLACEMENT [7 DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION i� SYSTEM REPAIR OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENOED USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial �.p_Oper; Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omastic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications . M Pliblic Cl Other ❑ Delta Depth of Grout Seal Type of Gout n � CI irrigation Approx. Depth ❑ Eeslern Surface Sed] Installed by r Repair Work Done � of pump_, • � _,_r H.p State Work Done Well Destruction ID Well Diameter �r+.^ Sealing Material i Depth Depth ` Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION-10 REPAIRJADOITION 0 DESTRUCTION Cl iNo septic system permitted if public sewer is Installation will serve: Residence Commerciale Otheravailable_ f within 200 feet.l Number of living units: Number of bedrooms f i Character of soil to a depth of 3 feet: # `Water table depth SEPTIC TAMC ❑ Type/Mig' Capacity _ 'No. Compartments A PKG. TREATMENTxP(,T. C1 �- ':♦i,J , Method of Disposal Distance to nearest: Well Foundation ^ property Line -4_7LEACHING LINE ❑ No. & Length of lines ..tante i Total length/size FILTfR BED Cl Distance to nearest; "`Well` � f Foundation propeny_Line, SEEPAGE PITS 11 Depth .f t Size JF Number SUMPS Ll Distance toynearest- Well Foundation DISPOSAL PONDS ❑ f Property Line 1�. 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signatuie 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 of sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." The applicant mus a all required inspections. Complete drawing on reverse side, # Signed Title; . - Data: R DEPARTMENT USE ONLY I Application Accepted by / / / Date r �F Area 119!j p Pit or Grout Inspection by Date _ Final Inspection by ' Data Additional Comments: Applicant « Return all copies to. e Q r p SAN JOA UiN-COUNTY-PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQuIN, P 0 Box 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCK INFO CASH RECEIVED BY DATE ' r n� PERMIT NO. 114-20. EH 17.21 IREV.t i n p! 6Yr / .04 . EH •2s �t C/✓ C� l