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APPLICATION FOR ,PERIdIT S r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION a 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 Na 1 - PERMIT EXPIRES 1 Y FRQM DATE ISSR 1� s 04 $ (Complete in Triplicate) _ I Application is hereby made to,San Joaquin County for a permit to construct and/or install the work herein de iiobnedof This application is made in complisnce�vith San Joaquin County ordinance No. 549 and 1862 and the Rules sad Regula Joaquin County Public Health Services. �7 City t S `ize/Acreage k Job Address Phone Owner's Name ddres Address f License No., Phone._ NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Ser VN Contractor vice Well ❑ TYPE Of WEL /P P: .r - OTHER ❑ Monitoring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ SEWER LINES �-- DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK - AGRICULTURE WELL OTHER WELL — PITS/SUMPS FOUNDATION k ! INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing * Industrial ❑ Open Bottom C3 Manteca Dia. of Well.Excavation Specifications - Cl Domestic/Private ❑ Type of Casing_Gravel Pack ❑ Tracy Depth of.Grout Seal -7— Type of Grout �- I'l Public Cl Other fl Delta i l Irrigation _Approx. Depth I I Eastern r Surface Seat installed by 4 H P State Work Done_ Repair Work Done U Type of Pump Sealing Material i Depth Well Destruction ❑ Well Diameter Tiller Material i Depth Dep11 th TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIAIADDITION I I DESTRUCTION a o'labPerw thin 200 feetc system .) if public sewer is E ¢ installation will serve: Residence Commercial— Other Number of Irving unity. Numtier of bedrooms Water table depth fff Character of son to a depth of 3 feet:I- M1 No. Compartments SEPTIC TANK D Type/Mfg Capacity - Method of DisposalPKG. TREATMENT PLT. M 11 Distance to nearest: Well Foundation Properly Line -----� t 7 Total length/size LEACHING LINE L1 No. b Length of lines property Line FILTER BED C1 Distance to nearest: Wail Foundation i SEEPAGE PITS 11 Depth It Size Number SUMPS CI Distance.to nearest: Well Foundation Property Line 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, state laws, and rules and regulations of the San Joaquin County re cenifies the following: "1 certify that in the performance of the work for which this permit is issued. I shall not Home owner or licensed agent's signatusub-contracting i ss- ampWy any parson in such manner as to become subject to workman's.compensation_Isws_of California." Contractor s hiring or sub connun'sg signature I unifies the following: "I certify that s the perforcome subje of the work for which this permit is issued,I shall employ persons subject to workman s compare tion laws of California." t The applic ust CA or all e4uired inspec ns. C 'i to drawin n revs s e � �c ills: t Date:'- F G r vrg� F DEPARTMENT USE ONLY ' -Date -- Area Application Accepted by Date ' Date. Final Inspection by pate Pit or Grout Inspection by 4 ► clp //� SC Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, p O Box 2009, Stkn, CA •95201 FEE CK RECEIVED BY DATE PERMITNO, INFO AMOUNT AMOUNT REMITTED CASH . 0.1 17 EM 13.24 IAEV.riK151 EH t1-26