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APPLICATION FOR PERMIT PA y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES R,ECLr tNT t ENVIRONMENTAL ' 90 HEALTH 'DIVISION JAN 19 1 445 N SAN JOAQUIN, PHONE (209)468-3420 Sall JOAQUIN SpA g93 P O BOX 2009, STOCgTON, CA 95201 PUBLIC IN COUNTY PERMIT EXPIRES 1 YEAR FROM DATE ISSUED VIRONM N�L HEALALTH TH SERV (Complete in Triplicate) DIVISION t s I� 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 frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San i Joiquin County Public Health Services. �(' r �docs f� Job Address I r r'" ® B Cit VJ�d� Lot Sine/Acreage l• fi'PS Owner's llama 26ZQ Addressy /9 1 _1k f A® �t/ ->7b l 'Phone Contractor OJ"IaM A/LCi � Address License No. 9a$-Phone - �7 h TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well : ❑ PUMP INSTALLATION O SYSTEM REPAIR �� OTHER D Monitoring well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE TAGRICUL-TURE WELL-__--OTHER WELL_— �—._ PiTS-lSUMPS' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ZI.-Mmestic/Private ❑ Gravel Pack, D Tracy Type of Casing_ Specifications I'I Public rl Other Fl Delta Depth of Grout Seal Type of Groul t I I Irrigation _ —.Approx. Depth�` I I Eastern Surface Seal Installed by Repair Work Done fSu3 Type of Pump 1 H.P. -. . � State Work Oona 6 tF ` .WaII_Destruction___❑_Well Depth Tiller Material ,& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I € DESTRUCTION I I (No septic system permitted it public sewer is �. available within 200 feet.I Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of wi<'to•depth of 3 feet: � Water table depth SEPTIC TANK. ` 0 Type/Mfg f Capacity No. Compartments PKG. TREATMENT PLT.❑ '.fi Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINEA ❑ No. a Length of lines Total lengthtsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line r r SEEPAGE PITS 11 Depth Size ' Number SUMPS LI_ Distance to nearest: Well _Foundation ,Property Line DISPOSAL PONDS C7 , I hereby unify 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 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 sub-contracting signature certifies the following: '4 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 mus call for allequired inspect' Complete drawing on reverse side. Signed * Title: Date: FOR DEPARTMENT USE ONLY / Application Accepted by i Data �- Area lwoe Pit or Grout Inspection b ry' = `+ Data Finsl Inspection by Data 6 Additional Comments: Applicant - Return all copies to: San Joaquin County Public-Health Services ' Environmental Health .Perinit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO. AMOUNT DUE AMOUNT REMITTED CASH- RECEIVED BY D TIE PERMiT'NO. EM 1324 IREV.1/$15) ��J / /t EH 14.76 [ l�= [�J