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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E ��.� ENVIRONMENTAL HEALTH DIVISION j P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 nl� 1''� +-� PERMIT EXPTRES I YEAR rRQX DATE ISSUED N "k�- iva (Complete in Triplicate) iR-.,t 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. -f' /5-7 - s,7 _ 2-(O -a,3 mob AddressfJ.4! rK i-, 45/00-4b Lot Site/Acreage 1,-Owner's Name ��LQ t. !n AddressS-C.0?_PD S-__ Abou Phone vCorilractor Address License No. Phone TYPE OF WELL/PUMP. NEW WELL © WELL REPLACEMENT C1 DESTRUCTIUR)g out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 171 Other ❑ Delta Depth of Grout Seal Type of Grout M Irrigation — Approx. Depth O Eastern Surface Seal Installed by f � Repair Work Done ❑ Type of Pump H,P. State Work Done_ W Well Destruction © Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAMIADOITION M DESTRUCTION iNo septic system permitted if public sewer is vailable within 200 feet.) Installation will serve: Residence — Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth o a Water table depth t SEPTIC TANK. ❑ T, s/Mfg rVDit No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal � E,I IVLIjn Property Line IIULI i LEACHING LINE ❑ No. �y.�Laingth oftRhos k�l I or ins Total length/size i rmF ��J�))��rrtt�n FILTER BED [i Dist e�tM1Ye�retft*M=w 1ii/ I 1�8 2f�ot�r� iion Property Line SEEPAGE PITS If Depth Size `Number -fi> SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 1 rules and regulations of the San Joaquin county Home owner or licensed agent's signature certifies the following: "I cavity that in the performance of the work for which this permit is issued, I shall not r employ any portion 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 at call for all req i d jrtsit ins. omplete drawing on reverse slde'. P/Signed Title: _Q_CQ&-,P t Date: _', OR D>~ ARTMENT USE ONLY Application Accepted by QDDate � Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 3 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 98201 IFEE A OUNT DUE OUNT REMITTEO CASH RECEIVED BY DATE PERMIT'NO, + EH t3441PEY,iinsr O� t ---0 ^C u D^ �b ' EN ud6 lJ �1