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..a APPLICATION FOR pERii1IT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 1 P O BOX 2069, STOCKTON, CA 95201 1 PERMIT EXPIRES 1YEAR FROM DATE ISSUED II (Complete in Triplicate) Application is hereby rade to San`Joaquin County fora permit to construct and/or install the work herein described. This application Is trade in coolpliance,vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. Job Address SD r ,#6 City Lot Size/Acreage n Owner's Name r Address ,l L 6A&4a&0-gP 6d Phone Contract Addres ( - )cense Phon e TYPE Of WELL/PUMP: NEW WELL �❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION I�� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ..� _FOUNDATION =L = AGRICULTURE WELL =L�OTHER WELL "'PITS%SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial ❑ Open Bottom, ❑ Manteca Dia. of Well Excavation Dia. of Well Casing IA-tromastic/Private ❑ Gravel Pack I ❑ Tracy Type of Casing_ Specifications I•I Public 171 Other f ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation I Approx. Depth t I Eastern Surface Saul Installed by Repair Work Done is Type of Pump H.P. State Work Done Well Destruction ❑ ' Well Diameter Sealing Material & Depth Depth "��~ • ' 11►111er Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPA-IRIADDITJON I I DESTRUCTION I I (No septic system permitted if public sewer is r,, avaiiable_within 200 feet.) ' Installation will serve: Residence_ Commercial____-�_Other� Number of living units: Number of bedrooms 4, , i rCharacter of soil to a depth of 3 feet: Watt ti SEPTIC TANK, ❑ Type/Mfg s'Capacity No.P� PKG. TREATMENT PLT.Clr— I s Met � �I �- Distance.to nearest:, Well—,Foundation Properly Lif an'lTV �g� � LEACHING LINE 0 No. 8 Length4of lines "� � Total length/aifi&N Ja �XWI*S t � FILTERS BED ❑ Distance to nearest: Well `—Foundation ProH f 4 ,_ flw� Et I SEEPAGE PITS 1.I De tptp h— gize'� Number t ALl :Distance to rtsaresf Well V Foundation SUMPS �,,`. _; ' P Lina --� +no DISPOSAL PONDS ❑ t t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawrules and regulations of the San Joaquin CountyHome owner or licensed agent's signature certi}ies the following: "I certify that in the performance of the work for which this permit is issued, I shemploy any person in such manner as to become subject to workman's compensation laws of Caii}ornia." Contractor's hiring or sub contracting sig certifies the following: "I certify that in the podormance of the work for which this.perrnit is issued, 1 shall emptoy persons subject W workman's compensa- tion Uwe of California." The applicant must call for all required inspectio e. Complete drawing on'."verse side. { Signed Title: _ Date: .-'� 1_p 3 FOR DEPARTMENT USE ONLY Application Accepted by _ Date Area ��} -^ Pit or Grout Inspection by Date Final Inspection by Date 3 l Addttional Comments: Applicant - Return all copies tor San Joaquin County Public Health Services Environmental Healt Permit/Services 445 N San Josqui P 0 Box 2009, Stkn, CA 95201 FEE IMFO AM DUE AMOUN REM TTEO= CK RECEIVED BY AtE P RMIT'NO, ,C # + fN ti3•Y4111EY.rin t I:M SI.7$ MAN/