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f ;* i �ZZL I— APPLICATION FOR PERMIT �` - - it V SAKI JOAQUIN COUNTY PUBLIC HEALTH S VIC n ENVIRONMENTAL HEALTH DIVISION �I k 445 N SAN JOAQUIN, PHONE (209)468-3420 € P O BOX 2009, STOCSTON, CA 95,201 C1C 3 , ��U it PERMIT EXPIRES 1 YEAR FR —MDTE�S fRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES Application is hereby made to Sa.a Joaquin County for a permit to construct and/or install the vork herein described. This nppl.lcetion is made in cor*liance with San Joaquin County Ordinance No. 5W'and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. cor'r 54C �{Mf11E City JI � Lot Size/Acreage Job Address ; s81� _n,oany� Address " Phone Owner's Name I _� U .� Contfactor D 'Ah nAt Address Bnx,33b.oo 1r if License NoS��Phone TYPE OF WELL/PUMP: EW WELL WELL fiEPLACEMENT n;, ' DESTRUCTION CI Out Mo oervitorieg Well C} Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑'3 OT ER ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES u` DISPOSAL FLD� PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial O Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing hL Domestic riv Ct Gravel Pack L] Tracy Type of Casing C 1 Specifications C I Pf,blic El Other Delia Depth of Grout Seal 0 ;! Type of Grout, tic f I irrigalion �.Approx. Depth t I Eastern Surface Seal lnstailad by �' Repair Work Done 0 Type of Pump H.P. ]f State Work Done } Well Destruction 0 Weil Diameter sealing Material i Depth I'. { Depth Filler Material i Depth d TYPE OF SEPTIC WORK: NEW INSTALLATION I i nEPAiR/ADDITION I I DESTRUCTION I I INo septic system permitted if prrblic sewer is available within 200 feet.) Mstallaiion will serve: Residence— Commercial_ Other ' Numtw of living units: Number of bedrooms k Character of sols to a depth of 3 feet: Water table depth + SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED C) Distance to nearest: Wall Foundation Property Line i ii t SEEPAGE PITS i I Depth Sire .Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL .PONDS ❑ f 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, end { rules and reguialions of the San Joaquin County I Home owner or licensed agent's signature certifies the following: "I certify that in the performance of.ithe work for which this permit is issued,I shall not employ any person in such manner as to become subject to workmen's compensation saws ollCelifornja." Contractor's hiring or sub-contracting signature s 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 taws of California." The applicant must call for an r rrad inspections. CompselA drawing on reverse side. �.f�.. Grp `�_9 Signed X - —_-- Title: C�� r�} Dole: q'� 3 f I FOR DEPARTMENT USE ONLY V Application Accepted by Date Area !� i� Pit or Grout Inspection by Date Final Inspection by Date I, Additional Comments: Applicant - Return all copies to: San Joaquin County Public health Services Environmental Health Permit/ServlceS 445 N San Joaquin, P O Box 2009, StkngsCA 95201. y r {i FEE AMOUNT DUE AMOUNT REMITTED % RECEIVED RY DATE PERMIT N0. j INFO CASH �tne ' Q - 00 , (D ZI13 q3 ZIS_ r • :EN 1T7�iilFV. V t