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APPLICATION FOR PERMIT I' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMLT EMIRES 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address,� City Cr Lot Size/Acreage Owner's Name �/ ��/ Address !?`�ek � Phone COntrdClOf r J !I1� Address! z&!t4 .0 1�N �G1 t'/� License N411/1& 7 Phon TYPE OF WELL/PUMP: NEW WEL ,WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ f PUMP INSTALLATION ❑ SYSTEM REPAIR C1OTHER 13Monitoring Well C] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � DISPOSAL FLD. PROP. LINE FOUNDATION �ifJ' AGRICULTURE WELL. OTHER WELL�,PITS/SUMPS T 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr Cl Industrial 11 Open Bottom C3 Manteca Dia. of Wall Excavation Dia. of Well Casing Domestic/Private �liravel Pack ❑ Tracy Type of Casing_ 101V C Specifications I'1 Public Cl Other + Cl Delta Depth of Grout Seal L of Grout I I Irrigation -17 Approx. Depth I 1 Eastern Surface Seal Installed by elf D,rJfl„M ,,,—_,.. Repair Work Done L7 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth MAICk.Ajo j00,,4 Depth biller Material & Depth TYPE OF SEPTICWORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if public sewar is jl _ available within 200 feet.) Installation will serve: Residence Commercial,.4,.• Other Number of living units: Number of bedrooms ZIP— Character of soil to a depth of 31eat: Water table depth r SEPTIC TANK. . 1 O Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT.❑ �. R Method of Disposal — Distance to nearest:. Well Foundation Property Line i LEACHING LINE ❑ No. 8 Length of lines Total length/size P FILTER BED 11 Distance to nearest:. Well Foundation Property Line SEEPAGE PITS I I Depth Siva Number SUMPS 0 Distance to nearest: Well Foundation Property Lira , DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and 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 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]rquat call�for all,required inspections. Complete drawing on reverse side. L Signed x_�lL_t Lr JLL�`�"`�.t _._...� Title: N 1 [ Date: �C�'�-�� DEPARTMENT USE ONLY Application Accepted by f"A,Au Date Area a Ph o Grout I spection by Date Final In by Date Additional Comments: 7 Z U Applicant —Return all copies -to: San Joaquin County Public Health Services 1 Environmental Health Permit/Services 445 N-San Joaquin, P O Box 2009, Stkn, OA 95201 i f INFO AMOUNT DdE AMOUNT REMlTTEQ CASH RECEIVED BY DATE PERMIT-NO. + #M i4•�6(REV.1!K51 f.1A � ! _ W