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fi APPLICATION FOR pERWI 1 SAN JOAQUIN COUNTY PUBLIC HEALTH E ENVIRONMENTAL HEALTH DIVISItRVICRS P O BOX 2009, STOCKTON, CA 95201 r (209) 468-,34,4,7 _0 00P ETA R , (Complete in Triplicate) Application is hereby mage to San Joaquin Count for a application is trade in COUPliance With San Joaquin County Ordinancermit to nNoru549ct aando18628snd CheeRulork ca hereinand described. ISai& Joaquin County Public Health services, tions 3128 W. Benjamin Holt Drive, Stockton,CA n Job Address City Lot Slze/Acre Owner's Name ExXOn �_�`� age COmDariy USA Address ins H 12 ouston, TX 77002 —222-6Phone Contractor — Address l TYPE OF Wl:LL/PUMP. NEW WELL D License NO,al 94 0 Phone it PUMP INSTALLATION ❑ E REPLACEMENT ❑ DESTRUCTION 0 Out of Service Neil 0 56 DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR O OTHER p Monitoring well i� —--�_ SEWER LINES DISPOSAL FLD, ' v FOUNDATION AGRICULTURE WELL j— PROP• LINE / M INTENDED USE OTHER WELL= PITS/SUMPS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f."i Industrial ---�— ❑ Open Bottom p Manteca Dia. of V�Excavation__ n EJ_DomeaticlPrivate FW Gravel Pack ' D'a, of Well Casino 7 IIS f M Public ❑ Tracy Type I Casing q0 IJ C r ---_ it Other Ol` J°Specifica(ions r v- `��41 CJ IrriUation © Delta Depth of Grout Seal O! ,I .�.Ap+WOK. Depth D Eastern --L"'=------.— Type oMrairt.�T�. ac',ti k c�. 7t' Repair Work Done {� Surface Soul Installed by.— Well Type of Pump ----__ H.P. •: Well Destruction Q Wel Diameter Seals Staie work sono M ng Material 4 Depth Depth F11ler Material & Depth TYPE OF SEP T)C WORK; NEW INSTALLATION 1;1 REPgfRlA04iTION L1 DESTRUCTION G fNo septic system permitted if public sewer is Installation will serve: Residence_ Commercial available within 2(X3 feet.) Number of livingunits: Other p� Number of bedrooms Character of soil to s depth of 3 feet SEPTIC TANK. ❑ Type/Mfg water table depth PKG. TREATMENT PLT, O Capacity�,—_____`� No. Compartments h Distance to nearest: WellMethod of Disposal --� _ Foundation Property Line l LEACHING LINE Cl No. & Length of lines FILTER BED ° fl Distance to nearest: yyeQ�� Total length/size Foundation� property Line SEEPAGE PITS I 1 Depth SUMPS Sias Number Cl Distance to nearest: Well DISPOSAL PONDS p Foundation-:.,__—_,__ Property Line 1 hereby certify that I have prepared this application and that the work will be done in accordance with San rules and regulations of rho San Joaquin county n Joaquin county ordinances, state laws, aril Home owner or licensed agent's signature certifies the following; "I certify that in the employ any person in such manner as to Become subject to workman's compensation laws of California," Contractor's hiring of sub-con. performance of the work for which this permit is issued, f shall na� certifies the fallowing; "I certifythat in the Performance of the work for which this permit is issued, f shall em to tion laws of California." ; " Pe t acting signature p p y persona subject to workman's compsnsa h lica - The appmust calf for al required inspections. Complete drawing on reverse aide. Signed C� �l, yr ran Title: ' Q,_ JL,� �$-F a Dote: / FOR DEPARTMENT USE ONLY ' Application Accepted by Pit or Grout Inspection by Date (P _ Area ip to------�, Final Inspection by t Additional Comments: Date Return all co /, APPlicant �- lea to: Q _ ? P SAN JOA UIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/$ERVICE3 945 N SAN .fOAQtfIN, p O BOX 2009, STOCXTON, CA 85201 FEELEjj!INFO UNT REMITTED CK CASH RECEIVED BY DATE P sv J � ERMiT'NO.