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~� APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH 5E AS " Y , P 0 BOX 2009, STMKTON, CA 95201 ENVIRONMENTAL HEALTH DIVISIXIV_ "11 i r` (209) 468-3447P �Qy &' V PERMIT UP RES I Y R (Complete is Tripp tate} + J�T��c � , Applicstlon is hereby made to Ban Joaquin County for a permit to construct and/or install the B ribed. This application is made in conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules a Agulations of San Joaquin County blic Health Services. Job Address 8 City, ---- Lot Size/Acreage Owner's Nam ddress t'h Contra er _Q,s e No. Phone TYPE OF WELL/PUMP. NEW WELL 0 WELL REPLACEM T 17.1DES RUCTION 0 Out of Service Well Cl PUMP INSTALLATION SYSTEM REPAIR 0 OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK4 / SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS } n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing � mestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications Ub 13 Public (:7 Other 9 ❑ Delta Depth of Grout Seal 4 I Type of Grout M trrivation —Approxi I 'E vein ""'`"glace Seul'lnst`ailntl kry i �" Repair Work Done 0 Type of P,umpI� H.P: ..State Work Done Well Destruction 0 Welt Diameter sealing Material,& Depth Depth - Filler Muter`ia1 'Depth �"�" " TYPE OF SEPTIC WORK; NEW INSTALLATION D. REPAIR-/ADDITION CI DESTRUCTION C1 tNo sep6oksyiiem permitted if public sewer is available,Within 200 feet,) Installation will serve: Residence Commercial Other t=. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O TypatMfg, Capacity No. Compartments ) PKG. TREATMENT PLT. Gl A�t ; Method of Disposal f I/ Distance eb nearest: Well Foundation Property Line LEACHING LINE 0 No. &.Length of lines Total length/size FILTER BED (_] Distance�to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property line y DISP_OSAL._PONDS-..._ 0 __- _-__ �: :►. .:: �.. :.�� 'f I hereby cenify 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 Sen Josquig I county Home owner or licensed agent's signaturl certifies 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 come subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature cantifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- don laws of California." The applica ust call r requiirre//dirispapions. Complete drawing on re erse side'. Till Date: /db/ /� - FOR DEPARTMENT USE ON J Application Accepted by Date +� Aree -'// Pit or Grout Inspection by Date Final Inspection by r Date �� 1 Additional Comments: i Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES I 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK f RECEIVED BY DATE PERMI7'NO. I . EH 13,24IREV.irn5; Z/ vv EH }