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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201. (209) 468-3447 PERMIT UPIR$-S__]._ YFAR_f)t{?ld, DATE SSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a Permit to construct and/or inetal.l the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address - 6 7 �• 1 �� City +� Lot Size/Acreage 3- r i Owner's Name" f ""_ S.044ft Address �r 7 �� L:IV e. o o Phone Contractor!► '�k Addre s License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK �b2c'L 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 BY Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications M Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout M frngation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. - State Work Done _ Well Destruction ❑ Well Diameter ^' � Sealing Material k Depth e . Depth 1_0_01 Filler Material & Depth n TYPE OF SEPTIC WORK: NEW INSTALLATION 10 REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted if public sewer is 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. ❑ Method of Disposal { Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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: "f 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 or subcontracting 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 must call for all re wired ins , tions. Complete drawing on reverse side. Signed T C g Title: � .- L/Ilk-4— Date: FOR DEPARTMENT USE ONLY Application Accepted by� ��L-��rJ Date ZC�//A�:,f0 Aree Pit or Grout Inspection by Date Final Inspection by ate Z i Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES R ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 68201 FEE AMOUNT DILE AMOUNT'REMITTED INFO LASH. RE CE IVA D BY DATE PE�R/M�iT'N�O, . EN 13-24 IREV.1/0151. ,7 tisk/ EH'.4'.26