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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 " (209) 468-344?' ,PERMIT EXPIRES_ I YEAR VRQX DATE_Jul (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the vork herein described. This application Is made in compliance vith.San Joaquin County Ordinance No.. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. /F Job Address % e City Lot Size/Acreage wner's Name _)e zz JIA Il A-Irf 4/ Address - Phone&-Za, Z3_21 Contractor.-a-1-1-W-4-i Address License No. Phone YPE OF WELL/PUMP. NEW WELL 13 WELL REPLACE NT 0 DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION SYSTEM EPAIR ❑ OTHER O Monitoring Well �� # DISTANCE TO NEAREST: SEPTIC TANK EWER LINES - DISPOSAL FLD. PROP. LINE ~ FOUNDATION A ICULTURE LL. .OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AS NSTRUCTION SPECIFICATIONS C7 Industrial EI Open Bottom ❑ Manteca is. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Typ f Casing Specifications M Public i'1 Other ❑ Delta Depth o rout Seat "Type of Grout G Irrigation _.Approx, Depth 0 East Surface Seal Called by C� Repair Work Done U Type of Pump H.P. State Work pons Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Mterial 4 Depth v] TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIRIADDITION L-I DESTRUCTIONf (No septic system permitted if public sewer is T vailable within 200 feet.) Installation will serve: Residence— Commercial Other Numberof living units: Number of bedrooms r Character of soil 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 r FILTER BED f:1 Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Siza Number 1 SUMPS Ll 'Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby comity that I have prepared this application and that the work will be done in accordance with Sacs Joaquin county ordinances, state laws, and rules and regulations of the Sart 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 F 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of la." X's The applic t mus call for all re aired ins tions. Complete drawing on reverse side,igned Title: �1/� ' Date:•,- F DEPARTMENT USE ONLY. Application Accepted byADate �- Area Pit or Grout Inspection by Date' Final Inspection by B, Data Additional Comments: ��/rrL+� rx� Applicant - Rat= all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P o BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERM11 NO, INFO CASH 9H s4.$tR . --Z 0 Ion 2-