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P APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC WRAITH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 PA Y a " P O BOX 2009, STOCKTON, CA 95201 " PERMIT EXPIRES 1 YEFROM DATE ISSUEDCE1 � ' AR (Complete, in Triplicate) 2 5 19,92 SAf4 JOAQt 1',�1 Crli +VT,, Application is hereby made.to Elan Joaquin County for a permit to construct and/or install the wor'ilb-ritVpAdescr4b� - phis application 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and thefRule�[t"d' ' guld�tto"s WAE*n JaaquiI County Public Health Services. r5'�' � �yj ION Job Address Cit gley4d Lot Size/Acreage Owner's Name &.b f tilM- -Q— to�[ Address Phone Canlractor ' �� Address License Nog_Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 1` OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST:_SEPTIC TANK SEWER LINES _DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL . PITS%SUNIPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ - LI Industrial c ❑ Open Bottom _0.Manteca_,_Dia. of Well Excavation Dia. of Well Casing _ rpomestic/Private ❑ Gravel Pack 13 Tracy Type of Casing_ Specifications s 11 Public n Olher fl Delta Depth of Grout Seal Type of Grout + } I I Irrigation Approx._Depth I I Eastern Surface Seal Installed by Repair Work Done IJ Type of Pump H.P. -- _ State Work Done 4i4 Well Destruction ❑ Well Diameter Sealing Material i Depth 9.r_ Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ j Method of Disposal Distance to nearest; Well Foundation Property Line LEACHING LINE ❑ No."B Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number x - SUMPS -^'+Ll =Distance to.rteanst: Wall----� - --Foundation--------^--.Property.Lina, DISPOSAL PONDS .❑ I hereby certify that I neve 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 I 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 shalt not employ any person in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or subcontracting sign ure certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's com tion laws of Callfornfa." The applicant must N for all required ins do Complete-drewing on versa side. 1 f Signed Title: _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date j y Area All 6 Z� Pit or Grout Inspection by Data Final Inspection by Date , Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DtJE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'No. 1 0' -� J/ CASH . EH13.24(REV.1 i R s) EH 14-M `,ice"