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APPLICATION FOR PERMIT � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION r P o sox 2009, STOCKTON, CA 95201 (209) 468--3447 YEAR PROM DAIE ISSUED (Complete in Triplicate) Application is hereby roads to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1852 and the Rules and Regulations of San Joaquin County Public Health Services. &t-t Sd _ City Lot Size/ re e r Job Address _ _ S` � 76 Owner's Neme,>�<'v-�� Address ��s Phone /r $-4 4 �t Z03 to mi- tIt ' License No. �`+ Phone Contractor s f� Address e-11 0 TYPE OF WELL/PUMP. NEW WELL,,Q� WELL REPLACEMENT 0 DESTRUCTION ❑ Out Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS riNTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - f_l Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation moi` r ""Dia..of Well Casing } U Domestic/Privals EI Gravel Pack ❑ Tracy Type of Casing Specifications 13 Public 11 Other CD Delta Depth of Grout Seal Type of Grout Irrigation ._.Approx+ Depth .0 Eastern Surface Seal knstalied by (moi F Repair Work Done U Type of Pump H.P. State Work Done �+ Sealing Material i Depth Well Destruction O Well Diameter - Depth Filler Material &.Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 9 REPAIR/AODITION 0 DESTRUCTION GI INo septic system permitted if public sewer is G available within 200 feet.) ` Installation will serve: Residence ✓� Comme%ial— Other , Number of living units: Number of bedrooms Y . .a ` Water table depth Character of soil to a depth of 3 feet: e " Capacity No. Compartments SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Welt Poundation � Property Line LEACHING LINE ❑ No. & Length of lines / s Total length/size FILTER BED n Distance to nearest: well 5 Foundation Property Line SEEPAGE PITS 11 Depth I Size Number SUMPS LI Distance to nearest: Well EEFFoundation Property Line � DISPOSAL PONDS ❑ '�•� . _ _.. •. — 1 �. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stela laws, and i rules and raguiations of the San Joaquin County I 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 tb become subject to workman's compensation laws of Celilornia." Contractor's hiring or sub-contracting signature 7 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall orrmploy persons subject to workman's compens,e- tion laws of California." j The spplic u off 811 required ins , tions. Complete drawing on reverse side. Signe CJY?rT Title: Date: ' rn b F DEPARTMENT USE ONLY rr / .2 b Application Accepted by Date Area, Pit or Grout Inspection by Date Final Inspection by Date D- � ql0 ear / s Wcl� �� wr7� gry�oc;� 7' G oYGP - d SYS rs trn yPuc Additional Comments: / f f t p jfyv✓�@_.� i�ar.'kLpi -�- .S'yS �..� W� rr �� C Lcc�T 4+� G Nett e 'L[/ ✓f'�@.. �� Applicant Return all copies to: SAN JOAQUIN C(3UNTY FUBLIG� SALT. SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 4413 N SAN JOAQUIN, P O 130 009, STOCKTON. CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY PATE PERMIT NO. INFO n_ + EH 13.24 IREV.I/x 51 � ��EH - 740 r F.