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APPLICATION FOR PERMIT A^ . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201. (209) 468--3447 YEAR rM PATE ISSIUM (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to cons truc t'and/or install the work herein described. This application is made in c=w1lance faith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �J Job Address v'�� '" �`-�� City ____� Lot Size/Acreage Owner's Name �oess �` `U' _ �.._. Phone �1 � Contractor !Y Address License No."A4=112 Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t of Service Well ❑ PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHE ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK --DISPOSAL FL•D, PROP-•LINE-� ��`^ ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ..._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom c10 Manteca ` ` -Die. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy �` Type of Casing Specifications ❑ Public I'1 Other ❑ Delta Depth of Grout Seal Type of Grout CJ Irrigation -- -..,�.Approx.`Deptf_O-Eastern "' $uiface$gal Instailnd`by '""' '� J, Repair Work Done 0 Type of Pump H.P, State Work Done Welt Destruction j Well Diameter Sesaing Material i Depth 4—jzo Depth Finer Material i Depths TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR-/ADDITCON-CI—EVESTRUC710'N-i*I'INo s6pnc system permitted if priblic sewer is X�, "`available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth a SEPTIC TANK ❑ -Tvpe/Mfg Capacity rt No. Compartments PKG. TREATMENT PLT. C1 X' Method of Dispodel Distance to nearest: Well Foundation � •Prapeny Line LEACHING LINE L1 No. B Length of lines. Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number = i 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: 1 certify that in the performance of the work for.which this permit is issued, I shall not i employ any parson in such manner as to become subjeci to workman's compensation laws of California," Contractor's hiring of 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 all rs a lions. Complete drawing on rove side. Signed Title: Date: Zo �zl1 s FOR DEPARTMENT USE LY Application Accepted by Data Area Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: I Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE�r INFO A MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. + EH 17.24(REV.,/KS, AM r ,