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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCHTON, CA 95201 (209) 468-3447 y Y R TH ISSUED' r (Complete in Triplicate) i Application is hereby WAO.to San Joaquin County for a permit to construct and/or inatall the work herein described. This application ie made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. rT City .q Lot Bite/Acreage 1 - Job Address i 9$ 33 b G[ 1 p O Jam`V'? u Phone Owner's Name _ 4-_ Address} .,� 4.L.Gt.GC c-F.a� r� • Cont+actor- t r `sem L. Address License No._(q Phone TYPE OF WELLIPUMP.xw�,,,.. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Mo Service Well [ �'r'" � �" OTHER O� Y Monitoring Well'-[T---- PUMP �. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ fDISPOSAL FLD. PROP. LINE JDISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDAIION_�_��. AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing n Industrial 1 <" '. ❑ Open Bottom ❑ Manteca, Dia, of Well Excavation Type o1 Casing Q Public Specilicatioris U Domestic/Private ❑ Grave� . lP�ack. L7 Tracy Type of Grout Other-- -� � �0 Delta - Depth of Grout Seal , _ t 1Y Cl Othet f G NriOsuan ^ Approx. Depthr 'Eastern• Surface Seal Installed by T -- H.P. SiateWnrk Done _ 7: Reps+i Work Oons L7 Type,o} Pump �.�. .ate. eria Sealing MMitl i Depth Well pesrructiota D W�1! Diameter _ .._. f�ept;�W- Filler Material i Depth 1 a TYPE Of SEPTIC WORK�.NEW INSTALLATION 0 REPAIRIADDITION DESTRUCTION ❑ fNo septic system permitted if public sewer is £ available within 200 fest.! Installation will serVtl: RBsidarics �Cominercial Other _ ,;w; �....g: -`Number of living nits. _J- `Number of bCedir�ocims Character oYsail to a depth of 3 feet: _ �+�'Y Water table depth SEPTIC TANK--s- -%�0-Type/Mig - "` °' Capacity No. CompartmentsJ. PKG. TREATMENT PLT,C7 v r'; Method of Disposal i bistance to nearest: Well L Foundation Property Line LEACHING LINE Irr r1o. Ii Length of lines r $e) - Total length/size y FILTER BED , D Distance to nearest. Well FoundatipwIL Property Lino-4)-- ',.SEEPAGE ine-4)- -.SEEPAGE PITS I I Depth Sire Number SUMPS "' LI-Distance to nearest: Well Foundation y Property,Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and ruies and regulations of the San Joaquin County -- , .- ,Home owner or licensed agent's signature certifies the following; "I comity that in the performance of the work for which this permit is issued, I shall not employ any person in ouch 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." t ,The applicant must call for all required inspections, Complete drawing on reverse side. t pate: Signed r Title: _ Wd= _.- - Ll ��'_ - r FOR,DEPARTMENT USE ONLY f r� � Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 'r 445 N SAN JOAQUIN, P 0 BOK 2009, STOCKTON. CA 95201 FEE OUNT DUE F AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO r ♦ EH 13.24[REV.1/w3ir.-