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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC EEALTH SERVICES C's+r a ENVIRONMENTAL HEALTH DIVISION y �. P O BOX 2009, STOCKTON, CA 95201 JUN 6igl r.. (209) 468-3447 ENVIi?ONMENTA1_ HEAL-rH PERMIT EXPIRES I XEAR tR M DATE ISSUED PERMIT/SERVICES (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 rade in compliance with Ban Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address t&As�) 1� _ City Lot Size/Acreage r Owner's Name P Address Phone Conlraclor�� 5rh�g.Addfess 40 S nse No,%396Z Phone .2$Y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION � SYSTEM REPAIR 91--� 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 SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ttl omestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications 1 ` M Public 1:1 Other ❑ Delta Depth of Grout Seal Type of Grout CJ Irrigation Approx. Depth ❑ EasternA Surface Seal Installed by U Repair Work Done Q_ Type of Pump A �_ State Work Done Well Destruction O Well Diameter Sealing Material i Depth { Ap++ Depth Filler Material i Depth V TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIWADDITION M DESTRUCTION G (No septic system permitted if public sewer is G available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of&oil 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 n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 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 must cal f r afl required 'ns ections. Complete drawing on rev se side. Signed }L Title: ....,, Date:—t AQ7 Appiic&tion Accepted by by MENT USE ONLY Date Area Pit or Grout Inspection by Date Final Inspection by 17 ate Additional Comments: Applicant - Return all copies to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMIENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT AEM1TTED CASH CK RECEIVED BY DATE PERMIT'NO, . EH 1I•24 fREV.I)K5) �4W