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. p APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 5 g —o5b k 445 N SAN JOAQUIN, PHONE (209)468-3420 V I P O BOX 2009, STOCKTON, CA 95201LA- PERMIT EXPIRES 1 YEAR FR M D TE ISSIZED , it (Complete in Triplicate) t;I 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 1$62 and the Rules and Regulations of San Joaquin County Public health Services.. _ ��Q p Job Address '3/ ' ''e"J�'"` `=` City Lot.Size/Acreage Owner's Name i Address��I Phone .r � 1y-� v��j k License No C ) J 7r.3_ Phone Contractor 'Oty�-G-' 0 d� Address TYPE OF"WECL-IPUMP:- —NEVA"WELL❑�� --'WELL REPt=ACEMENT-Pi-- DESTRUCTION-B Out of Service Well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS \ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications f'1 Public 1-1 Other' } n Delta Depth of Grout Seal Type of Grout Ih Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Or Type of Pump?��' H.P. State Work Done Wed Destruction D Well Diameter i'4 Sealing Material &.Depth 1 I Depth 1 Filler Material i Depth ! TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is I s available within 200 leet.l ,Installation will serve: Residence_ icommercial ' Other Number of living units: Number of bedrooms w Character of sod to a depth of 3 feet: J Water table depth SEPTIC TANK. O Typo/Mfg i Capacity h" ; No._Compartments - 1' PKG. TREATMENT PLT.© moi - `Method of Disposal Distance to nearest: Well Foundaiion Property Line � I LEACHING LINE Ll No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation-i Property Line SEEPAGE PITS 11 Depth ` Size Number SUMPS LI Distance to nearest: Well Foundation Property Line i 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 I - 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 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 st call for all r quired inspections. Complete drawing on reverse side. ' •. ��q 3 Signed x Title: Date: R DEPARTMENT USE ONLY Application Accepted by Date Area O Z..- Pit or Grout Inspection by Date Final inspection by Data / Additional Comments: Applicant - Return all copies' to: San Joaquin County Public Health Services Environmental Health Permit/Services 446 N San Joaquin, P O Box 2009, Stkn, CA 95201 I FEE INFO AMOUNT DUE AMOUNT REMITTED CK ECEIVED BY DATE PERMi7'NO. . EM 13.24 IREY.r I� EM ts2s LLJJ