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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 YEAR PROM_DATE I SSU, (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 tirade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �iv-e Lot Size/Acreage Job Address R City Owner's Name Lk 0-1—S u"'`elr _ Address f Z o �� p .�� Phone !/ Contractor u 1`-t ��kt p�ri(/ef� Address 1 v� ^f�� + nee No.` --Id Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION,9, SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications �I Public f 1 Other ❑ Delta Depth of Grout Seal Type of Grout M Irrigation Approx. De��p►►th�ii� ❑ Eastern Surface S I Installed by Repair Work Done U Type of Pump ©i�______. H.P. S -- State Work pone {y Well Destruction © Well Diameterrr ISealing Material 6 Depth r Depth j"I 7 Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of wit to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments PKG, TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation 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 Sen 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 workmen'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." The applicant u call for al quir d tnspections. Complete drawing on reverse side. L/��2 `� Signed Title: ��r -- Date: ` 4-- FOR DEPARTMENT USE ONLYApplication Accepted by ^ C _, !4 �-- Data _tt'2:3Area Pit or Grout Inspection by {late Final Inspection by i Date Additional Commants: Applicant - Return all copies to, BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 IFEE NFO AMOUNT DUE MOUNT REMITTED CASH RECEIVED BY DACE PERMIT'NO. . EH 13-24 IREV.=inSl V0 oa`B 'A P_ EH A-2e v