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APPLICATION FOR PERMIT % SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Y ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 QNrbx PERMIT EXPIRES 1 YEAR 'FROM DATE ISSUED 2R' (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules end Regulations of San Joaquin County Public Health Services. C Job Address 3 q City 6c-f—�- Lot Site/Acreage l / I l/ �-U1 Address � 7c� Phone Owned Name T/ Contractor �j {l� ��'� Address 1 I—= (cense No. Phone ��7 �64 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well ❑ _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 O Industrial ❑ Open Bottom ❑ Manteca Dia, or Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation _Approx. Depth ❑ Eastern - Surface Seal Installed by Repair Work Done U Type of Pump H.P. E State Work Done _ Well Destruction ❑ Wall Diameter Sealing Material a Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION,ar, DESTRUCTION ❑ (No septic system permitted it public sewer is available within 200 feet.) `, Installation will serve: Residence� Commercial _ Other Number of living unite L Number of bedrooms Character of coil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg FD NC<-e-ft Capacity-./-6-0 G No, Compartments Z PKG. TREATMENT PLT. ❑ Method o1 Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines - T O Total length/size i FILTER BED ❑ Distance to nearest: Well /v'`� >`' Foundation /fid� Property Line SEEPAGE PITS 11 Depth Size '� Air Number SUMPS LI Distance to nearest: Well -LT?0-t Foundation.I-:�0 Property Line DISPOSAL PONDS O 1 hereby certify 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 cenifies the following: "I certify 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 subcontracting signature certifies the following: "I certify that in the performance 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 forr all required inspections. �Complete drawing on reverse side. Signed X f _GC-C��( �i�i"h""—- Title: r z:11f — Date: FOR DEPARTMENT USE ONLY licnion Accepted byfV� Date 1 =Z-�-�Z d Area 21 /;Pit or Grout Inspection oy-�✓ Date �`I Final Inspection by�l"" � Date) 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 SOX 2009, STOCKTON. CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. NFO CASH "EN 13 }N;4.2e IaEV.i r x ar _ v-s ____