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APPLICATION FOR PERMIT !0oeM 1 BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 4 BOX 2009, STOCKTON, CA 95201 PERM T EXPIRES I YEAR FROM DATE I S (Complete` in Triplicate) I Application is hereby made_to San Joaquin County for a permit to construct and/or lnatall 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 Josquia County Public Health Services. Job Address 4b � 1�+M�e.• - City Lot Size/Acreage Address .1 Phone ~ Owner's Name1VO ++ Contractor Address License No, b�% Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 fl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t� I'1 Public 1'1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction Well Diameter 4 f Sealing Material i Depth Depth Q7 s Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is l� available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living unit: ' ' Number of bedrooms w Character of sell to.a depth of 3 feet: Water table depth SEPTIC TANK. ❑- Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal' Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ 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 oUtK6 work for which this permit is issued, I shall not employ any person' such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies tfre fa "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 is o n a-1110M. The applic m call for all requ' inspection omplete drawingo to ss side. Sig, Title: Date: FO"EPART T USE ONLY ` Application Accepted by Date Area Etto Date f 3 P$or Grout Inspection by Date Final Inspection by i Addhlonal'Corm ments: Applicant - Return all copies to: San Joaquin County Public Health Services k Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 4 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'NO. i INFO CASH / . EM!}2�tREY. /R51 ��/� C //o , . to / 04 11.70