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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENV I RONMENTAL HEALTH DIVISION P O BOX -2009, STOCKTON, CA 95201 (209) 468-3447' f PER1[IT E%PIRES 1 YEAR FROM DATE ISSUED ` C!`�=� �- � - �(Camplete in Triplicate) 12-7 Oft-71 t� Application is hereby tiide,to S&6 Joaquin County for a permit to construct and/or install 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 Joaquin County Public Health Services. !/ .Ns✓� -/s.� Lot Size/Acreage Job Address _, � ;�,� �-�;f��e� �'�3 City AF_ � Owner's Name �� -✓ /�/�>YrWl�df/L,Adtl ss „ l m `&2 :;4,1 6 Phone 2 Contractor Hi ddress tL;0� License No. Phone TYPE OF WELLIPUMP: NEW ELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �t Monitoring Well G7 So,L e6r_,o DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE V FOUNDATION AGRICULTURE WELL. OTHER WELL PITSISUMPS iti INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS d 0 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing r U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications � j R Public is Other 0 Delta Depth of Grout Seal Type of Grout I G Imoation w Approx..Depth 0 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done , Well Destruction ❑ Well Diameter Sealing Material i Depth I' Depth Filler'Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/AD ITION 0 OESTR TION G iNo septic system permitted if public sewer is � available within 200 feet.) Installation will serve: Residence Commercial �.._.. Other Number of living units: Number of bedrooms Character of $oil to a depth of 3 feet: Water table depth SEPTIC TANK, O Type/Mfg, Capacity No. Compartments Pli TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well ndation Property Line LEACHING LINE C1 No. & Length of lines Total length/sire i FILTER BED ❑ Distance to nearest: Well Foun on Property Line I fh[J SEEPAGE PITS 11 Depth Sii Number ]"° SUMPS Ll Distance to nearest: I Foundation Property Line II DISPOSAL PONDS ❑ z 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signature cartifies 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 sub-contracting signature a certifies the following: "I comity that in the peRormance of the work for which this permit is issued, I shall employ persons subject to workman's Compensa- tion laws of California." { The applicant call !r?al r aired nspec 'ons, Complete drawing on reverse side. / Signed Title:,M4;.tlT� /Zrl� /.GL. Date: 1,k I DEPARTMEN USE ONLY Application Accepted by Date Area 1' Pit or Grout Inspection by Date r Final Inspection by Dante Additional Comments: �^ o� a+ r Ir r^l tQ- a ,.e- rep L14- "y Ct� Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES a 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 FEE 17 INFO MOUNT DUE AMOUNT REMIT-TEE) CASH RECEIVED BY DATE PEFiMIT'NO. . 1111]•2�iNEV,rn51 t-26 , o-� tC?� ��+ ��3" 10 -3v13 teM: •i