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tf� APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � 1R �{1 �� ENVIRONMENTAL HEALTH DIVISIONS 1 '1 P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447tij� :P:CRMIT 9M189§ I YEAR P]99X DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH Application is hereby made to San Joaquin Count for PERMh'T1 9 pP q y permit to construct and/or install the work ere n bed. 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 &Pik) bU y.0 Spq w• L�&4�LJ City 16 L __._ Lot Size/Acreage t Owner's Name s .131: ,ne Address b W SI.A-e-1' Phone M-069 SIawt7 9S$2Y S License No. Su4 Phone� Address 282- !L4 ue ` W -47 TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT f_l DESTRUCTION ❑f'''t of Service Well C.1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �yMo�M ng Well C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �5�t DISPOSAL FLD, PROP. LINE *-t �5e P FOUNDATION Cir AGRICULTURE WE6k--qRL—� OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t M Public 11 Other ❑ Delta Depth of Grout Seal Type of Gro t G Irrigation ,_.- Approx. Depth 0 Eastern Surface Seal Installed by e Repair Work Done LJ Type of Pump H.P. State Work.Done _ Gal(-n Ur H} Wall Destruction ❑ Well Diameter Sealing Material A Depth , p Depth Filler Material i Depth 1 � ' TYPE OF SEPTIC WORK: NEW'INSTALLATION 0 REPAIRIADDITION Cl DESTRUCTION CI Wo septic system permitted if public sewer is " available within 200 feet.) Installation will serve: Residence r Commercial— Other . Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth �7 SEPTIC`TANK. p Type/Mfg Capacity LNo. Compartments i PKG. TREATMENT PLT,C1 Method of Disposal Distance to nearest: Well Foundation Property Line ° LEACHING LINE Ll No. 8 Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line 4 SEEPAGE PETS 11 Depth Sire Number SUMPS Li Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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-contracting signature certifies the following: "1 certify that in the performance of the work for which this permit if issued, I shall employ persons subject to workman's compensa. tion laws of California." The applican u call for all requirgd i pe.. tions, Complete drawing on reverse side. Signed Title: .,,..._-- Date: 2- byd FOR PEPARTMENT USE ONLY Application Accepted by Date ` 0 Area f` Pit or Grout Inspection by Date �/ o Final Inspection by Date Additional Comments: Applicant - Return all copies to:- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 INFO EEE AMOUNT DUE AMOUNT REMITTED 0 5N RECEIVED SY DATE PERMIT'NO. tl - • EM 13.241REV. /I//�/ �� `,�70 ILI EM 1.4-202e