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f APPLICATION FOR PERMIT k SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O SOX 2009, STOCKTON, CA 95201 (209) 468-3447 ` PERMIT 1 YEAR ERO (Complete in Triplicate) Application its hereby rade to San Joaquln'County for a permit to construct and/or install the work herein described. This application le made in compliance with San Joaquin County Ordinance No. 549 and .1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 06a "' A City +-ey g' Lot Size/Acreage Z s rte-},- Address S tri Phone Owner's Name V rbr� !, .w__...,�. _.�.. _�_�____�tM..f`.�-c:-_tom l(•t:r--•- �.-_ ,>_.._..,..�...�.._.___.._._._.,.. ....__..�__-�-.a.�...__.._.�..- ..-. ,�-. �.�_ .. �..,.,�. .9 r ...� -� License No, ij `$SS4hone Contractor Address W Out of Service Hell TYPE'OF WELL/PUMP: _ NEW WELL O WELL REPLACEMENT 0 'DESTRUCTION Cl ❑ . fR ..,._. .�' _b -ER C]�Y-- Monitoring...Wel-1...L1. •� f ~� PUMP INSTALLATION Q SYSTEM REPAIR ❑ - OTH DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES DISPOSAL FLD. PROP. LINE ---'-. . ..._ _,. .AGRICUI {•UPE WELL'"'_'._.. OTHER WELL -_ 'PtTS/SUMPS .� FOUNDATION . -- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G7 {ndustria{ p Open Bottom ❑ Mani Manteca Dia. of Well Excava4ioA Dia. of Well Casing l Type of CasingSpecifications U Domestic/Private 04rayel•Pack 0 Tracy ❑ Public Cl;OType of Groutther,., � ❑ Delta Depth o} Grout Seal ,- n Irri{lation .Approx. Depth 0 Eastern Surface Seal Installed by State Work Done Repair Work Done U Type of„Pump H.P. Well Destruction ❑ Well Dia-m- Wer t Sealing Material i Depth Depth ---_. --Filler-Material i Depth.< TYPE OF SEPTIC WORK: NEW INSTALLATION i7 REPAIR/ADO1TlON 'DESTRUCTION-G "o' o septic system permitted if public sewer is Q - •-t avaitable within 200 feet.) CJ Installation will servo: Residence— Commercial :.Other- Number of living units: __�_ Number of bedrooms Character of soil to a depth of 3 feet: . �w"+. "s�'� ' _—Water table depth SEPTI TANK. ❑ Type/Mfg t Capacityi No. Compartments PKG.PTREATMENT PLT, Q Method of Disposal I r Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Totgl length/Size FILTER BED 0 Distance to nearest: Well __.31 — Found iff6riProperty Line_. SEEPAGE PITS l I Depth Size SUMPS istance to nearest: Well 50L:!L Foundation.��. Property Line DISPOSAL PONDS ❑ _r___.._. .., _. ._ I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and 71 rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall not 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 California." The applicant must call for all r wired inspections. Complete drawing on reverse side. Signed Title ^-.e-,r . Dote: FOR DEPARTMENT USE ONLY _ �� Application Accepted by Date Area 2� Pit or Grout Inspection byDate Final Inspection by Oats Z � 1 Additional Comments: Applicoxt - Return all copies tot SAN JOAQUIN COUNTY PUBLIC HEALTH $BRVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 CK 9 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. FO . EH 13.24IREV.I I WA ,cJa &D 2960 EH 1{•:a