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APPLICAMW SAN WAQUIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 EMIT EXPIRES 1 UM Z= DAM-j== (Complete in Triplicate) Application is hereby mmds.to Baa Joaquin County for a permit to construct and/or lnsiadl the work herein described. This spplltlatiou is ride in camplimnoe with Sae Joaquin County Ordinance No. 549 and 1$52 and the Rules mad Regulations of San Joaquin County Public Health Services. Job Address 132,& City Lot Size/Acreage Owner's Nam (N o n \' rens Phone / Conttttctor b!AyMjffdretsMAjQlicense No.614 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE ❑ Moaitorimg Well 1� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE n FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation Dim. of WM Casing n Dommstic/Private 0 Gravel Pack ❑ Tracy Type of Caning Specifications 1'1 Public 11 Other n Delta Depth of Grout Seal Type of Grout I I Nfigation _Approx. Depth i I Eastern Surface Ssal Installed by Repair Wont Done EJ Type of Pump H.P. tete Work Dont Wall Destruction 10 Weal Dkarnettr f f SaalinS Material a Depth &dTga .tfxt re Depth truer Material ik Depot 61 am Ia 12AW TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION i 1 (No septic system permitted d pubk sewer is available within 200 fest.) + Installation will sow: Random— Commercial_ Other Numtw of living units: Nut*w of bedrooms Character of soli to a depth of 2 feet: Water tabb depth SEPTIC TANK ❑ TV"/Mfg Capacity No. Compmrmients PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: We11 foundation Property Lim LEACHING LINE ❑ No.i Length of rules Total length/sire FILTER BED ❑ Diistance to nearest: Wall Foundation Property Lime SWAIM MTS I I Depth Sire Number SUMPS LI Distance to rttsnest: Wall Foundation Property Lint DISPOSAL PONDS ❑ 1 hmrft certify that I haw prtptrad this application and that the work will be done in accordance with San Joaquin county ordinsntos, statt laws„ and pulse and rsgufatkals of the San Joaquin County Now owner or lip i vsd apoWs signature cmnifise Ow following: "I certify that in the perfamaoce of the work for which tflis permit is bound, I shall not employ any parlor in such waww as to bwAmpap subject to workman's cornponsatiak laws of CoWomis."Conamctoes hiring or wb•conaa ft signature omr!lfima the fdowfrtg:"I certify that in the performance of the work for which this permit is bsued.I shall employ persons wbjtct to workman's compenss. don bat of CaWamb." Tike ca! mquired ktspoeftne. Complete drra tg on reverse skit. 2 Q Signed Tide: g dA- Date: J Do FOR DEPARTMENT USE ONLY Applkatlon Accepted ho 2n Daft Area ,�.yy� r Dat Pk or Grout Inspection incl 1 /�� iDr Additional COrrk nwMM: •-- 7161 Applicant - Return all copies to: San J ui County Pu a Heal 411 Baru ccs NoviroasltataI Health Permit/Services 445 N San Joaquin.. P O Sox 2009. Stkn, GA 95:01. PH INF AMOUNT DUE AMOUNT REMITTED A RECEIVED OY ')AYE PE mv,NO. , .EM1}atINV.tFasp IN 14110 ........._. ......--- - _.._ .. - -....._ - .. ......... _........___.__,.