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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r1M , ENVIRONMENTAL HEALTH DIVISION U Yl �� 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON , CA 95201 �J� ,gT� 3(,gy) PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDQ (Complete in Triplicate) Application is hereby rade 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. 54 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r� / AAA—. �_ � 1�J1lLf �! r.,, �/L�AJi7zLot Size/Acre"e Owner's Name �/ / z`�i�LJ�%[ T% Address 70-� /t4y-c— '51r• :+o Phone S '. ,4tb Contractor �Zifw. ?r , ''�*R ��Address _- 'Tf _ ,✓� X/4-1 S License No. Phone ' :'7f r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTIONE�t of Service Well ❑ DATE PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O 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 ❑ Industrial ❑ Open Bottom )O Manteca Dia. of Well Excavation ., Dia. of Well Casing Cl Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing-=� `? Specifications I"1 Public T' Other F1 Delta Depth of Grout Seal _ Type of Grout I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H. P. State Work Done _ Well Destruction .13� Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feetA 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation _ Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 shall 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: "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 CaY}ornla." / The applicant' ust call for all hequired spagons. Complete drawing :nr" side. � r � Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by ` ` _ Date -� ( Area r _ ' Pit or Grout Inspection by Date `� Final Inspection by 7iL Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services J 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 EH 13-24 (REV. r i n s. EH 14-2e FEE INFO AMOUNT DUE AMOUNT REMITTED CK f - CASH RECEIVED BY DATE PERMIT N0. �• j l,_�� /iI� �-� q l�� L�ll 9-7 a- a