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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 11 ENVIRONIMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YE FROM D TEissplaa (Complete in Triplicate) r� 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 cottiliance Frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Lot Size/Acreage Job Address /r-c G/� S ��i+v1 r.Y Owner's Name �• Address �µ. _ Phone_ fi �f / License N Phone Contractor • i+ Address •- be - TYPE OF WELL/PUMP: NEW WELL,,13, WELL'REPLACEMENT-L] -DESTRUCTION Ll out of Service Well LI PUMP INSTALLATIOWE)7 SYSTEM REPAIR ❑ OTHER ❑ Monitori-rig well ❑ DISTANCE TO NEAREST: SEPTIC TANK 1- SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I 0 Industrial C3 Open Bottom ❑ Manteca Dia. of Well,Excavation. - Dia. of Well Casing ' t Specifications fa Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ I'l Public f.I Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Work Done W State tate ot Repair Work Done [J Type of Pump i� j- s s % Well Destruction ❑ Well Diameter?"f Sealing Material i Depth j nth i { Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION (No septic system permitted'if prbfic sewer is 3; T available within 210 feet ) Installation will serve: Residence Commercial—_-Other. Number of living units: _ Numbeu of•-bedrooms it 'Water table depth r 1 1 ? Character of'soll to a depthoi-3 feet: E„ _.,_ vl i SEPTIC TANKI 0 Typi/M1g"� Capacity, . No. Compartments T PKG. TREATMENT PLT.Cl _4A f �1. '''": '"Method of Disposal ' �/� -_Property,Line: - I Distance to nearest: Well Foundation # i LEACHING LINE C1 No. 8 Length of lines ��-Toot�ta--1 length/siie FILTER BED - i�Distance to'nearest: Well Fou..._r?dation ��.,, 8roperty Line ��a � - s SEEPAGE PITS I 1 Depth Size 7 Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PO`t1DS"'.""°...0„- -" 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, nd rl` rules and regulations of the San.Joaquin County r 1 " 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 she not employ any person in such manner as to become subject to workmen'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 Lem of California." .Jj i The applicant must cell fOrJ0 r ed in iona.'Gamplets=drawing on reverse side. Signed X Title: _ Date: F9 DEP TMENT USE ONLY ,� 1 r. Application Accepted by Date Area - F Pit o►Grout Inspection by Date Final In b Dats-� r ; r Additional,Commants Applicant - Return all copies to: Sae Joaquin County Public Health Services Environmental Health permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE f AMOUNT REMITTED CKSH RECEIVED BY DATE PERMIT NO. I INFO . EN 1344{REV.1 n 61 flop EN 14.76 Anx