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APPLICATION FOR PERMIT SANJOAQUIN COUNTY PUBLIC HEALTH SERVICES J ENVIRONMENTALHEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 { .. (Complete in Triplicate) This Application is hereby made to Sant Joaquin County for a permit to construct and/or install the work herein described. application is made in cowliance;with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Servicee. 13 (� - �. .��#C�"�4C J !}C City e -� Lot Size/Acreage �Job Address << } �1 7 .' 5��414 'r,Jf_ nj, (�Sr �v• LCh.ve. sr�c lf� • Phone KOwner's Name TT Address _-, Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Ll D OTHER ❑ Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ LL 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 pia of Well Casing f_1 Industrial ❑ Open Bottom. ❑ Manteca pia. of Well Excavation t„ �`" '� jType o1Casing ` Specifications — L) Domestic/Private. ❑ Gravel Pack 0 Tracy � Type of Grout R Public I-1 Other i( ❑ Delta Depth of Grout Seas CJ Irrigation --APprox•'Depth ❑ Eastern __Surface Seal Installed by H.P. ""T""`-`state Work Done M Repair Work Done L3 Type of Pump Sealing Material & Depth Y Will Destruction Diameter Destruction D r-- i Depth ^`P111er Materi Z-Depth --- - Nose system TYPE OF SEPTIC WORK; NEWINSTALLATION 0. REPAIR/ADDITI DESTf1UCTI0N BvaiVabPe�w within 2t�0 leen=ad �f public sewer is} s Installation will serve: Residence _� Commercial_.. Other - - Number of living units: Number of bedrooms Water table depth Cheractef of soil to a depth of 3 toot:T No. Compartments SEPTIC TANK: TM D Type/Mig Capacity Method of Disposal. PKG. TREATMENT PLT. Gi f f :�r_- Distance to nearest: Well _—^ Foundation property Lino i.� LEACHING LINE ❑ No. & Length of lines _ Total length/size FILTER BED Foundation Property Lino, n Distance to nearest: Well Fo s 1 - SEEPAGE PITS I I Depth Site Number SUMPS Ll Distanco,to nearest: Well Foundation Property Line ij DISPOSAL PONOS ❑ 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 cenify that in the periarmance 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 Calilornia.-Contractor's hiring or sub-contracting signature certifies th ollowing "I certify th the pertormenca of the work for which this permit is issued, I shall employ persons subject to workman's compenss- tlon laws 1 Gslifornf ." The applie at Cal r quire inspections. Complete drawing on reverse side. �igned rf Title: v�lt^�f Date: 11 / F T-_USE ONLY Date b' Area Application Aeee t by Date e �,� i~ µ.ms S 7�t�•-'e � S u� Final Inspection by Gate Pit or Grout Inspection by 'Gd/Ps may- us .t�7`�— ! Additional Comments: !'� t ,u moi- ${o�c&t rs ll.ay. Applicant - Return all copiers to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES S,14-wr-- �, l�T c r' r� ENVIRONMENTAL HEALTH DIVISION PERk1T/SERVICES 445 N SAN JOAQUIN, P O SOX 2008, STOCKTON, CA 8520 FEE GK RECEIVER BY ATE PERMIT MOUNT DUE AM UNT REMSTTEO CASH INFO /�•� � t/�!' �q Q7 Ell 13-74 IREV.i/wSl Q-�� Eii 1446 V V