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I .« `APPLIGATION FOR'PERMIT , f ;. SANJpAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRON1TAL HEALTH DIVISION dEN 1601 E. HAZELTON AVE. , PRONE CA095201-5420 P O BOX 2009, STOCgTON, EXPIRES 1 YEAR FR M DA E (Complete in Tripcate) li made to San Joaquin County for a permit to construct and/or install the work herein described. s -Applicatiou ,ie hereby _ application is;made in compliance with San Joaquin County Ordinance-No.�549 and 1862 and the Rules and Regulations of an Joaquin.County public Health Services. r ( city Lot Sire/Acreage 14 G S _ c ' . Job Add(ass g { # Phone Q Addrass o� d� y wner's Name ,_�� r . I� Phone A License No. 11 Address DESTRUC11 TI11 ON ❑ Out 1.111,of Service Well Contractor WELL flEPLACENIENT ❑ Monitoring Well p NEW ELL ❑ _ pT-HER ❑.._ = ;,J TYPE OF WELL/PUMP; �SYSTEM..AEPAIR-.❑---��r-"' t PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE �. SEWER LINES __ --- PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK �---� AGRICULTURE WELL _ OTHER WELL�r i FOUNDATION ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing � -- INTENDED USE p Manteca Dia. of Well Excavation _ t I li+dustrial ❑ Open Bottom Specifications ❑ Tracy Type of Casing Type of Grout f7 Domestic/Private: 0 Gravel Pack y Depth of Grout Seal V ! Public F y I.] Other n Delta _ Surface Seal Installed by a,Cnigatian ___ Approx."Depth i I Eastern State Work Done 4 H.P. pair Work Done L7 Type of_Pump �_ Sealing Material & Depth Destruction ❑ Weil Diameter _�----- Filler Material eL Depth II Depth available within 200 feet.) / I' OF SEPTIC WORK: NEW INSTALLATION 4 1 REPAIRlADDITION i ! RESTRUCTION 4 I (No:septic syitem`permitted if public sewer A+ Others=- v ...,..f installation will serve: Residence— Number Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: Dapacity___� No:-Compartments � y SEPTIC TANK. ❑ Type/Mfg Method of Miposal PKG.. TREATMENT PLT. 0 -Foundation — Property Line -- "Distance to nearest:' . Total length/size LEACHING LINE Cl No. & Length of lines WProperty Line } _{ Foundation _�---� �+- FILTER BED ❑ Distance to nearest: ell---- --- Size Y Number -_ SEEPAGE PITS 11 Depth Property Line Foundation �— a..y� SUMPS LI Distance to nearest: Well�— i DISPOSAL PONDS ❑ �L,hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state aws, Tule��a,nd regulations of the San Joaquin County 1 certify that in the performance of the work for which this permit Is issued, I shall not s Horne-owner or licensed agent's signature certifies the following; ' Ia." Contractor's employ a4"rson in such manner as the rf become sub ce ofsignature 4 othe work afor which this permnsation it is issued, I shall employ persons lsubf cring rt to wo�kman!scompensa certifies the fo%wing:"I certify that n pe r -" tion The applicant must call' r�r uir inspections.Tbmplete drawing on'reverse Sid Date: Title: v Sign d X f 'FOR DEPARTMENT USE ONLY 7� 3 —1r-SCJ Area Date I App4icacion-Accepted by `} Date ; rte " Final Inspection by f Date�--- Pit of Grout Irtspe�tion byr (� zCi/2 Additional Comments., r q3 les to: San Joaquin County Public Health Appliea.nt - Return all cop Services;�Hnvironmental�Health Permit/Services 1601 E. Hazelton-Ave., P a'Box2009, Stockton, CA 95201 PERMI7f Nd. SCK. � RECEIVED BY DATE f FEE AMOUNT DUE AMOUNT REMITTED GASH. ! + INFO 611113-24(R V.i/1%51 _ I A-26 Ifk.