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i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTONI, CA 95201 �I (209) 468-3447 PERMIT EMIRAS-1;4 R FILE COPY (Complete in Triplicate) Application !a hereby made to Sous Joaquin County for a permit to construct and/or install the vork herein described. This application is made in c1 liance with Ban Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Services. 2A?3 JPA A _ 5'rZd/ Lot Size/Acreage /� x a. 7�--__- Job Address City Owners Name 161 A m �_e7'' Address 5 Phone Contractor__E_"_222 ou Address 7 A 4Pff4gcr,o—r±!!/ _ License No. Phone - 7 TYPE OF WELL/PUMP: ' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O 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 In Industrial 010pan Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private 0(Gravel Pack ❑ Tracy Type of Casing Specifications M Public f.1 COther p Delta Depth of Grout Seal Type of Grout G !I Irrigation g �� .Approx. Depth ❑ 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 - 1 Depth )tiller Material 11 Depth TYPE OF SEPTIC WORK: NEWINSTALLATION 0 REPAIR/ADDITiON DESTRUCTION G fNo septic system permitted if public sewer is .��` ✓ available within 200 feet.) Installation will 'serve: Residence ._.. Commercial^ Other Number of living units: __L_ Number of bedrooms,A . Character of soil to a daptfi'of 3 feet: e Water table depth SEPTIC.TANK ❑ a Type/Mfg �'e -� Capacity Zo a No. Compartments PKG. TREATMENT PLT, ❑ .3 Method of Disposal Distance to nearest: Well Foundation S� Property Irina � LEACHING LINENo. S Length of lines __I---ArE1 '_ _ Total length/size ,,FILTER BED n1�Distance to nearest: Well /40-0, 't- Foundation _/6 Property Line S' SEEPAGE PITS f IkDepth Sired Af Number 3— SUMPS Ll Distance to nearest:. Well a0 Foundation f® � Property Line s DISPOSAL PONDS ❑ :1 hereby hereby certify that 1 haveprepared this application and that the work will be done in accordance with San Joaquin county ordinances, aisle taws, and rules and regulations of the San Joaquin County I 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 „amploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature I certifies the following: "I certify that in the paiformance of the work for which this permit is issued,-I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for alllrsquired inspections. Complete drawing on reverse side. Signed 7L> 2-�-� fy f Title: _- Date: P FOR DEPARTMENT USE ONLY Application Aaceptod by EEEE�0, �1 Date �_ Area Pit or Grout Inspection by � Date Final Inspgot" Date S 'Additional Comments: ."Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLI EALTH SERVICES j� E:NVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES I 445 N SAN JOAQUIN, P.O BOX 2009, STXKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH AECEIVED By DATE PERMIT NO. + FM 7i•�(REV.I/pl 61 4li d� Li O -c;r-4D