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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 0 o Yv (209) 468-3447 2 SIT EXPIRES 1 YEAR 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 with Sar. Joaquin. County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. _I 2 - Job Address 170f _ C40()� Ci'J L� City �'y X s� Lot Size/Acreage 0g �Z5 r — I Owner's Name ' `r Address 306 gA4 — Phone Contractor 1tG4VVCt TYPE OF WELL/PUMP. DISTANCE TO NEAREST NTFNr)Fr7 ttgF M Industrial U Domestic/ Private M Public MI Irrigation Repair Work Done U y� Well Destruction ❑ Address NEW WELL PUMP INSTALLATION ❑ SEPTIC TANK FOUNDATION License No. Phone DA WELL REPLACEMENT ❑ DESTRUCTION El Chit of Service Well ❑ SYSTEM REPAIR CI OTHER 11Monitoring Well SEWER LINES 1 DISPOSAL FLD, PROP. LINE = AGRICULTURE WELL OTHER WELL PITS/SUMPS _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Open Bottom ❑ Manteca Dia. of Well Exca alian "f/ h ' l63ravel Pack ❑ Tracy Type of Casing- _ - 11 Other Delta Depth of Grout Seal rIF 1_2Approx. Depth ❑ Eastern Surface Seal Installed by Type of Pump H. P. St to Wo�S. Donk_ Well Diameter- Sealing Material i Depth t.J`r� r Depth-- Filler Material L Depth Jr--;,, it Dia. of Well Castn Specifications _�', ` _ t1 Type of Grout � vvy� _,i, ?-'4 LL - PE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/ADDITION LI DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) I L-A Installation will serve: Residence — Commercial _ Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: SEPTIC TANK O Type/Mfg PKG. TREATMENT PLT. 0 Other Capacity Distance to nearest: Well Foundation Water table depth _ No. Companments Method of Disposal Property Line _ LEACHING LINE Cl No. 8 Length of lines _ _, Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth _ Size _ _ _ Number SUMPS LI Distance to nearest: Weil _�_._ Foundation _ Property Line DISPOSAL PONDS ❑ co 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, ander rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies 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 California." %® 1P Tilip The applicanmust call for al�,red inspections. Complete drawing on averse side. Signed X. ,1"�--''� _Title: l_" Date: FOR DEPARTMENT USE ONLY Application Accepted by _ Data l� 30 /9'y/ Area Pit or Grout Inspection by .� DateFinal Inspection by _ Date Additional Comments:y/CLI `-�� _� 1/6uJ� fr Z— __C _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES O �� ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 EH 13-24 IFEV. I, �5. EVa -4.26 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. f 03