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APPLICATION FOR PERMIT JOAQUIN COUNTY PUBLIC HEALTH SERVICES SAN Q I ENVIRONMENTAL HEALTH DIVISION � P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 pEMIT EWIRES I YEAR ?RQM DATE_ ISSJ1 (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 1562 and the Rules and Regulations of San Joaquin County Public Health Services. Job Add reu ZB 'v � City �scALo.tl Lot Size/Acreage xl4tt;OF _ Address 2510 C1 L611110v AVC . 650940A/ Phone 9319-12314- Owner's Name -Rose �11 Contractor Address License No. Phone j i TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl I PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ? Depth of Grout Seal Type of Grout M Public Cl Other ❑ Delta � O : M Irrigation ^Approx, Depth © Eastern 4 Surface Sea! Installed by Repair Work Done U Type of Pump H.P, State Work Done_. Weil Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW'INSTALLATION f"'REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Z Commercial— Other Number of living units: ---L_ Number of bedrooms Z - Character of soil to a depth of 3 feet: r4M L,p Water table depth SEPTIC TANK. I# Type/Mfg o Capacity j2Oo6-L No. Compartments PKG, TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well_coo Foundation 1A _ Property Line LEACHING LINE IND. & Length of lines r '� Total length/size Z�W '" 2- FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS lµ Depth ZQ FT Size Number d SUMPS LI Distance to nearest: WellFoundation F7-Property Line 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 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 shell not employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub•contfacting signature cenifies 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 Californls." The applicant t call for all required inspections. Complete drawing on reverse side. ` t CiP•r Signed Title: Date: x_'30~� OR EPARTMENT USE ONLY �` - - - � Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection br' Dated Additional Comments: -- Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMRNTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO ( ` t CASH INEv.iiAs) i`�tL...le