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APPLICATION XPR.PERMIT SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES r Or�U r ENVIRONMENTAL HEALTH DIVISION TSf�v� P 0 BOX 2009, STOCKTON, CA 9520 . (209) 468-3447 PERMIT EXPIRES 1 YTAR ?ROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coetpliance with San Joaquin County Ordinance No. 549 and 1 62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ► City Lot Siie/Acreage Owner's N 0 U12 013ik)llb Address Phone ' Contraclo �'�ddress • ...7 K License No �Phone TYPE OF WELL/PUMP: NEW WELL 0- WELL REPLACEMENT Cl DESTRUCTION i of Service Well Gl PUMP INSTALLATION ❑ s SYSTEM"REPAIR 0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES `" DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f_l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing fJ Domssticl Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications R Public i Ott r ❑ Delta Depth of Grout Seal Type of Grout CJ lrriUatj4n , •y- -T� pprox. Depth ❑ Eastern Surface Sea! installed by Repair Work-Done Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler )Material i Depth /I TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIAOOITION M DESTRUCTION G INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial r Other ! Number of living units: Number of bedrooms a Character of Boil to a depth of 3 feet: 0 Water table depth SEPTIC TANK ❑ Type/Mfg `' ' F" r 1 '. Capacity No. Compartments PKG. TREATMENT PLT. Cl r '�,� .. F Method of Disposal Distance to nearest: Well + > Foundion- Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED F) Distance to nearest: Wells Foundation Property Line SEEPAGE PITS 11 Depth Size, Number r I SUMPS LI Distance to nearest: Wellf ' J,Fovndation Property Line DISPOSAL PONDS ❑ �! y I hereby certify that I have prepared this application and thafthe work will be done in accbrdance with San Joaquin county ordinances, state laws, and j rules and regulations of the San Joaquin County i Home owdficonsagent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ anh manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies thcertify that in the rf ansa of the.work for which this permit is issued, I shall employ persons subject to workman's compensa-tion lows The app' or all requir pections. C mpl rowing rev r rdSign4C Title: r Date: ` t R t&PARTMENT USE ONLY Application Accepted by Date��L"I L Vfr _ Area Pit or Grout inspection b Pe Y Date Final Inspection by Date Additional Comments Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445.N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA-95201 FEE INFO OUNT DUE AMOUNT REMITTED CASH ' --kRECEIVED BY DATE PERMI7'N0. . E„13.2244(REV.i/As) `7 - ` a f �� q�� -�87 �!