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f APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 iUMIT .E )RES 1, YEAR ?RQM_PATE _1=01 i (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to,construct and/or inatall 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 Servicje�s.. JobAddress _7Z7r %1/ �, d.t� City Lot'Size/Acreage 610 ` Owner's Name �a� � /Yl/7�/1 _ Address - Phone ' Y-Contractor Address License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Beryl ce"Well-01 PUMP INSTALLATION 11SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U DISTANCE TO NEAREST:'SEPTIC TANK "� SEWER CINES Mn " " DISPOSAL FLD, =— PROP. LINE FOUNDATION AGRICULTURE WELL '";OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _S ' n Industrie! r ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ' O Gravel Pack: ❑ Tracy Type of Casing Specifications D Public Cl Other ❑ Delta FDepth-of Grout Seal - Type of Grout C3 lrnUation —Approk, Depth C1 Eastern Surface Saul Installed by Repair Work Done U Type of Pump. H.P. I,, �"^ S446 Work Done Sealing.Material & Depth Well Destruction ❑ Well Diameter, ' Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D .REPAIR/ADDITION CT DESTRUCTION A(No septic system permitted if public sewer is r available within 200 feet.) Installation will serve: Residence Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: X Water table depth r SEPTIC TANK: } 0 Type/Mfg � Capacity � No. Compartments PKG. TREATMENT PLT.❑ ,' I ,•,�, r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No, 8 Length of lines Total length/size• r FILTER BED ,0 Distance to nearest: Well Foundation Property 6he SEEPAGE PITS 5 I 1 Depth Size Number SUMPS #Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I# ) 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 canities 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 subcontracting signature certifies the following: "I certify that in the parlormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I S The applcnt ll f r all required ins ctions. Complete drawing on reverse side. j h ` Signed Title: Date: /o/x,• r F EPARTMENT USE ONLY + lD `I S'��._ Application Accepted by Date Area ll Pit or Grout inspection by i Date Final Inspection by Date /d , Additional Comments: , ,r Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION- PERMIT/SERVICES :445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 98201 \' sI FEE AMOUNT DUE I A OUNT REWTTED CK RECEIVED BY DATE PERMIT'N0. INFO CASH . EH U•71 iREV. /R r,1 �� t tam C r o-L�'o 90-a76 EH;4•� L