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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRES IIYEAR FROM DATE ISSUED (Complete in Triplicate) Application 1a hereby esd< to San Joaquin County for a permit to conetruxt end/or install the work herein described. This application is aside in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public HeallthhService#. / 7 -/ -_;� r- r:.., Lot Size/Acreaste / b I hereby cenify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, anu rules and regulations of the San Joaquin County Home owner or licensed agent's signature canines the following: "I cenily that in the performance of the work for which thin permit is issued, I shall not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or suFcontracting signature certifies the following: "I comfy that in the performance of the work for which this permit is issued, I shalt employ persona subject to workman's compansa lion Iowa of Califorrda." The applicant MAW call squired inspections. Complete drawing on reverse side. (^ O Signed 1! r- - -�-�� Tills: (f_1�------ '�� Dats: ® F R DEPARTMENT USE ONLY q Application Accepted by x Sisazti N Date 'V_ a- ` 1 Z Aro Pit rout 1 tion by L-Uate S J.S RJ final Inspection by -IY,=/P pets r� 1 Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN• P O BOX 2009• STOCKTON• CA 95201 WPO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO I �S r T•� Il �n s 2s-+<_ Phone Own it s Name % V I - ddiess 1<4/-1 �� `o 3.53 /`�- L icense No. 7Z Phone Contractor SS Address TYPE OF WELL/PUMP". NEW WELL 91WELL REPLACEMENT _ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION P__� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK x[70' SEWER LINES r DISPOSAL FLO./-5 0 PROP. LIN&L"l'- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TVP F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f_l Indus ial pen Bottom ❑ Manteca Die. of Well Escevation Out. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing lz eR Specifications ❑ Public ❑ Other ❑ Delta Depth of Grout Seat O Q 46 Type of GroulEz!-Clal- C� O lrnUation Approx. Depth Eastern Surface Seal Installed b /� �•- - Repair Work Done Ilia Type of Pump H. P. Z State Work Done _ Well Dest uctlon ❑ Wall Diameter Sealing Material a Depth Depth Tiller Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/AOOITION ❑ DESTRUCTION O fNo septic system permitted it public sewer is available within 200 leet.l Installation will serve: Residence _ Commercial _ Other Number of living urdts: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. g Length of lines Total length/size FILTER BED ❑ Distance to monist: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Lim DISPOSAL PONDS ❑ I hereby cenify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, anu rules and regulations of the San Joaquin County Home owner or licensed agent's signature canines the following: "I cenily that in the performance of the work for which thin permit is issued, I shall not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or suFcontracting signature certifies the following: "I comfy that in the performance of the work for which this permit is issued, I shalt employ persona subject to workman's compansa lion Iowa of Califorrda." The applicant MAW call squired inspections. Complete drawing on reverse side. (^ O Signed 1! r- - -�-�� Tills: (f_1�------ '�� Dats: ® F R DEPARTMENT USE ONLY q Application Accepted by x Sisazti N Date 'V_ a- ` 1 Z Aro Pit rout 1 tion by L-Uate S J.S RJ final Inspection by -IY,=/P pets r� 1 Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN• P O BOX 2009• STOCKTON• CA 95201 WPO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO I �S r T•�