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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENV I RONMENITAL HEALTH D I V I S ION P O BOX 2009, STOCKTON, CA 9kb" (209) 468-3447 �. YEAR (Complete in Triplicacenbl6me-1. /��y- Jra �^- - Application is hereby tirade to sea;Joaquin County for a permit to construct and% �f �}� ork Aerein described. This application is made-in compliance with San Joaquin County Ordinance No. 549 and he�a 04?Regulations of San Joaquin County Public Health services. r <C / �G ��4`Areage Job Address &b© y � _ CitL /�C t Owner's Na .!. � Address Phone A9 v I aXo� ss I nse No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACE NT n DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION SYSTEM REPAIR O OTHER ❑ Monitoring Well [1 DISTANCE TO NEAREST: SEPTIC-TANK SEWER LINES DISPOSAL FLD. PROP. LINE r FOUNDATION{ AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE uTYPE OF"WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- — " - f1 Industrial>' ❑'Open4Bottorrr ,^'" p-Manteca 5 r pia. of Well Excavation f Dia. of Well Casing Qpmestic/Private C7 Grayal Pack-, I:r0 Tracy f. Type of'Casing Y �- Specifications. - M Public x I:1 Otlier� p,Delta Depth of Grout Seal -?Type of Grout M Irrigation _Approx.. Depth E stern Surface Soul Installed by H.P, Repair Work Done 1j. Type of Pump //NeOiarer�! ter, i hWell Destruction t'O1 lsBeP i00p1h / Filler Material i Depth TYPE OF SEPTIC—WORK:--NEVI+'-INSTAi CAT10N-f;l- -REPAtR-hADf)lT10N-1"f—DESTRUCTION-Ci-••fNO-septic system permitted if public sewer is f s } available within 200 feat I Installation will serve: Residence I Commerciale-- Other Number of living units: Number of bedrooms O i Character of soil to a depth of 3 feet: yr Water table depth SEPTIC TANK ❑ Type/Mfg �� Capacity No:`Compartments PKC. TREATMENT PLT. C3 Methrid of Disposal Distance to nearest: Well Foundation PropertyyLine LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED 17l Distance to nearest: Well Foundation Property Line A SEEPAGE PITS I I Depth 1 Sire Number f SUMPS LI Distance to nearest: Well Foundation Props rty Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the v{ork 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 subcontracting signature canifies the following: "1 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 call for pit re uired inspections. Complete drawingon r6i7 side: Signed Title: V//,--a A-/ Date: FOR DEPARTMENT USE ONLY �I r Application Accepted by Date "��' ��/ Area All l Pit or Grout Inspection by Date Final Inspection by Data 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 2009, STOCKTON. CA 88201 FEE AMOUNT DUE AMOVNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT NO. + EH 13-24 IREY.t51 E H^,{-2a