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€I i `- APPLI;C.ATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES iµ ENVIRONII[ENTAL [iEALTH DIVISION ii P O BOA 2009; STOCKTON, CA 95201 (209) 468-3447 Ij R ' ' it f Ru _X$IR 1 YF i tnp113te in Tri ! (Caplicate? Apr Inion is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coawliance with San Jioaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 11 .9 Job City Lot Size/Acreage car y Job Address r s y „ (ff -ii lig Address ,7T - , l`c �-t � _ _ Phvn( , Owner'i Name II # l I icense No. Y�� Phon Cont,ac to ldress TYPE OF WELL/PUMP. NEW WELL 0!I I WELL REPLACEMENT LI DESTRUCTION Ll Out of Service Well El OTHER sfZ1 Monitoring Well [J PUMP INSTALLATION 01; SYSTEM REPAIR ❑ �.}.- w) r DISTANCE OXREST: SEPTIC TANK Lf^ SEWER, LINES /�0,�. DISPOSAL FLD.� PROP, L1NE,_'�,�f '��' 'f 1 FOUNDATION — .��0 I__ AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS 15 x-- LcY,�,/C f"J Indu,atriel 0 Open Bottom 0 Manteca jt Dia. of Well Excavation Dia. of Well Casing Ll DomesticIPrivate ❑ Gravel Pack I.] Tracy I I Type of Casing._ Specifications D Public f"1 Other 0 Delta ! Depth of Grout Seal Type of Grout G trr,0ation Approx. Depth ❑ Eastern Surface Seal Installed by_ Repair Work Done 0 Type of Pump � H.P.1 State Work Done _ Well Destruction O Well Diameter 3I' Sealing Haterial 4 Depth �� I1 Dep 1 th iG Filler Material & Depth !: TYPE OF SEPTIC WORK: NEW INSTALLATION L i REPAIR/ADDITION C1 DESTRUCTION 0 INo septic system permitted if public sewer is i til available within 200 leet.l fnsteflation will serve: Residence — Commercial_ Other } Number of living units: Number of bedrooms Character of roil to a depth of 3 feet 'll l I) _ —Water table depth SEPTIC TANK0 Type/Mfg Capacity No. Compartments l PKG. TREATMENT PLT. Cl i,; Method of Disposal p Distance to nearest: �!Well Foundation Property Line ` i` LEACHING LINE L-1 No. 9 Length of lines ;i II Total length/size t FILTER;BED CI Distance to nearest: '� Well Foundation Property Line SEEPAGE PITS 11 Depth II! Site- ! it Number SUMPS LI Distance to nearest: i!i Well II Foundation _ Property Line 1 DISPOSAL PONDS 0 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 regutations of the San Joaquin County ii I Home owner or licensed agent's signature certifies th011',ollowing: "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 pwrnil is issued, I shall employ persons subject to workman's compensa- tion lows of Californle." II itl ` The applicant of call for all required inspeI ctions. Complete drawing on reverse side. j Signed iX �' L ,r.� 'i Title: �� Date: 3 1 �— ' WENT USE ONLY Application Accepted byDale �' a Pit or Grout Inspection by I Date II Final Inspection by Date ` Addition$[ Comments: Il Applicant - Return all copies to: SAN JOAQUiIN COUNTY PUBLIC HEALTH SfiRVIL`fi3 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 4 i 445 N SAN. JOAQUIN.' P O BOX 2009, STOCKTON, CA 95201 w S __ IEEE AMOUNT DUE AMOUNIT REMIT-TEO I CASH CK RECEIVED BYDATE Ip PERMIT NO. ^ . EH 1771 fREv;i/.�! I° H H .Y