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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONIMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 i PERMIT XPIRES 1 )EAR FROM DATE_ ISSUED {� (Complete in Triplicate) 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 frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address t flCity Lot Size/Acreage r wner.s Name Address l�7/ld 555-Ti.ri Phant� d rontractor T Address License No. Phone YPEOF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O,_ Monitoring Well ❑ 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 n Industrial ❑ Open Bottom " ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing_ Specifications I'1 Public n Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal:lnstallod by Repair Work Done 0 Type of Pump H.P. State Work Done --Well Destruction O Well Diameter I Sealing Material A Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ `Commercial— Other Number of living units: Number of bedrooms ' .1 Character of soil to a depth of 3 feet: 1 Water table depth SEPTIC TANK. 0 Type/Mfg !I Capacity No. Compartments PKG. TREATMENT PLT, C1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. m Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ul Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl ;I 1 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 feguloWns of the Son Joaquin County Horns 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 net employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatur certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's compensa- tion laws of California." The applicant must call for all r ad inspections. Complete drawing on rev side. l i Wsionsdx Title: ri,L Date: EPARTMENT USE ONLY Application Accepted by _��1g � Q�j Date �°-C Area Z ` Pit or Grout Inspection by Date Final Inspection by—_ Date Additional Comments: Amor- �TLfill /L� Giarv►D _. _ ,.__..,_ ,._....,_......._. Applicant - Return all copies-to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE � INFO AMOU7NT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'ND. . EN13.24 I11EV,i/e W 5�) em 14.20 1