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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CAf95201 (209) 468-3447 2=11 EXPIRES I R - ar (Complete in TriplicV'vn. tna , � } s Application is hereby de,ta San Joaquin County for s permit to construct and/or s ,�,herein described. This application is made in cotilpliance with San Joaquin County Ordinance No. 549 and 1862 and- / Regulations of San Joaquin County >e�cg� �Public Health Services. �S+ Job Address CC/ �-� -AL1 City Lot Size/Acreage Owner's Name jggaCf reds C frac �r , iNo. Phone TYPE Of WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT DESTRUCTION 0 Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._. INTENDED USE TYPE OF WELL PROBLEM AREA"-CONSTRUCTION SPECI-FICATIONS = i7 Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing _>.�Mgleslic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications M Public f:7 Other ❑ Delta Depth of Grout Seal Type of Grout CJ frripation —Approx. Dept h Eastern /`S ace Seal Installed by Repair Work Done 0 Type of Pump H.P. 1 at r _ Well Destruction ❑ Well Diameter Sealing Material & Depth ��/ ,(,f Depth Fi"lies lia�EeriaT'i'Dep�Ti"" 0&_ TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION M (No septic system permitted if public sewer is available within 200 feet.) r) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No, Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lina rS SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line +� DISPOSAL PONDS Cl i hereby certify that i have prepared This application and that the work will be donein iccorda`nce with San Joaquin county ordinances, stale Isws, 8nd rules and regulations of the San Joaquin County 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 J 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." The applicant usrea9 foall 'rod inspections. ,Complete drawing on rev a side. Sign d V"--/ Title: Date: Fif p ARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by , Dats� Additional Comments; Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON. CA 85201 FEE INFO AMOUNT DUE /n� AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO. + EN 13-21 IREV.l/n51 �VEJ � EN.{.2e