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` APPLICATION FOR PERMIT ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONNENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, .CA 95201 (209) 468 3 _-50 ]?EMIT EMIRASI YEAR PROM DATE 15�U D (Complete in Triplicate) . Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This . ma application is de in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public HetA- alSew�,ces Job Address D City Lot Size/Acreage Owner's Name 0 _Sk rt+6 Address ILL O p S or Phone Contractor f1Q4U`? LI; lC tel ddress 6Df S A.12 rka' License No. 'T' OO -_Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERMonitoring well C7 JrpIL.6oRINrQ S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 0 fft#caEA'-: _ Dia. of Well Casing O fig Domastic/Private ❑ Gravel�Pack ($Tracy Type of Casing AIPAlE _ Specifications M Public 0 Other AIC*/A14-6 O Delta Depth of Grout Seal io Zte swic"ALE Type of Grout&6§X&�� C trripa6cin ,LCZ Approx. Depth ❑ Eastern Surface Saul Installed by A�!} - Repair Work Done 0 Type of Pump N.P. State Work Done_ Well Destruction O Well Diameter Sealing Material fi Depth I Depth Filler Material f: Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION L"1 DESTRUCTION ❑ INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence — Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compenments PKG. TREATMENT PLT.Cl Method of Disposal. Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. A Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Sire Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I 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 certifies 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shail employ persons subject to workman's compensa• tion laws of"California." The apptican m st c I for ed inspections. Complete drawing on reverse side. �� ,, Signed Title: -�� "-,% t1-J O(-%,I (*tk,� Date: FOR DEPARTMENT USE ONLY Application Accepted by Dat Area Pit or Grout Inspection by Data Final Inspection by Date VV VV 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 CK FEE INFO AMOUNT DUE AMOUNT REMITTED nGASI RECEIVED BY �( DATE PERMIT 19 1- E . EH A, tNEV.iinSi "�! •`-"" CASA 1 1- �I EN; .26