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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 X R IROM (Complete in Triplicate) f worX in Application is hereby made.to ,IthuSanCJoaq,uo San in County Ordinance rmit to nNo. 549struct aand o1662aand 1the eRules andeRegulationsdof Sane application is made in comp Joaquin County Public Health Services. r LlL� City Lot Size/Acreage Job Address 241,15 1 Phone ry110-Ut � Address Owner's Name Conlfaclor e. NC Address License No. �r�� Phone NEW WELL ❑ IN£LL REPLACEMENT Cl DESTRUCTION ❑ Out of Service WelWell ❑ TYPE OF WELLIPUMP: OTHER ❑ 15 Monitoring Well 5Y57£M REPAIR C1 -�+If-- �rr+�rS PUMP INSTALLATION ❑ M SEWER LINES __.:�-- DISPOSAL FLD. PROP. LINE - DISTANCE TO NEAREST: SEPTIC TANK -- PITS/SUMPS FOUNDATIDN AGRICULTURE WELL OTHER WELL_ --^ INTENDED USE TYPE OF WILL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Manteca — r Dia. of Well Casing L� Industrial ❑ Open Bottom ❑ Manteca Dia, a! Well Excavations Specifications ii Type o1 Casing --�---- U Oomesticl Private ❑ Gravel Pack ❑ Tracy .Depth of Grout Seal _ Type of Grout r_1 Public Other ❑ Delta G Initiation Approx. Depth ❑ Eastern Surface Setri Installed by State Work Done �t±se► Repair Work Done L] Type of Pump ��--- H'P' t�laterjal i Depth Seals Well Destruction ❑ Wal! Diameter ; --- Filler Material i' Depth Depth ` TYPE OF SEPTIC WORK: NEW INSTAtiLATION ❑ 111F. A.111.1 CI OE STRUCTION CI availableNo rwithin 20tem 0 feet.) if public sewer is Installation will serve: Residence I Commercial — Other — Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: f No. Compartments tN SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT. ❑ { Distance to nearest: Well Foundation— Property Line .--- Total length/size LEACHING LINE D No. b Length of lines Property Line FILTER BED Cl Distance to nearest: Well Foundation 1 1 Size SEEPAGE PITS l I Depth Number Property Line �— SUMPS LI Distance to nearest: WeII Foundation DISP05AL PONDS ❑ I 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 signature shall not employ any pens n in such manner as to became subject [o workmen's compensation laws of California." ploy co ; ubl of tobwookman'scompensa- Certifies the fol wing: "I certify hat in the performance of the work for which this pe MIT is iaeued, l shah employ parsons tion laws of allfornla." 't } r,. 60 The applica t u t call for a require sped' ompIota drawing on ►e e e side. 5 ` ,/ r fr Date. // Signed Title: DEPARTMENT USE ONLY J� Date res ' T � Application Accepted by + - pate Final Inspection by Date Pit or Grout Inspection by Additional Comments: :I Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES t 445 H SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 GK RECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMiTtEO CASH INFO - . Eli 13-74 Utfv,r/r RRl7 61 � �/ Q 01C. i' t