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h APPLICATION FOR PERMIT f, TK " ; SAN AQUIN COMM PUBLIC HEALTH RVICES RECEIVED ENVIRONMENTAL HEALTH DIVISION GO ,r+T 2 ��2 445 N SAN JOAQUIN, PHONE (209)468-3420 GOO P O BOX 2009 STOCKTON, CA 95201 SAN JO,,QUIN! C01JN—,Y '!iSUC HEALTH SER'v?CES p T BSI $ EAR FROM DATE ISSUM1Rr0Nr,,',EN7,AL"EALT14 DV-;1Si-,3'.s\J (Complete in Triplicate) Application is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This application is made 1n cowliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address - I 1 O T k v r^'�� City 5-�taz.k Irl Lot Sime/Acreage �• 6 A L Ye So,�-lrtila.� v- Address Y % Phone Owner's Na �y 3 43(�?� ro s�i D �1 Contractor V t Wer III dress t d Zt 19 nsrtJ o• O Phon tQ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION El Out of Service Well ❑ Npnftori S Well O ® PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER lad+ 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 17 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation ti � Dia. of Well Casing Ne n Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Agxwe Specifications I'l Public f l Other n Delta Depth of Grout Seal -'' �S — Type of Grput vv -4 r { I Irrigation Approx. Depth I I Eastern Surface Seal Installed by V, ( 0 ~ - Repair Work Done U Type of Pump H.P. State Work Dons Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADOITION I I DESTRUCTION I l (No septic system permitted if public sewer is available within 200 feet.) Installation will sem: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of will to a depth of 3 feet: Water table depth SEPTIC TANK, ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest Well Foundation Property Line r LEACHING LINE CI No. @ Length of fines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest Well Foundation Property Lira DISPOSAL PONDS ❑ E I hereby certify that I have prepared this appiica6m 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 becorns subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cardfies 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 cap for an required insptrcticrs. Complete drawing on reverse side. f Signed Titla: Date: 0 ZZ/P� J C � 4707,51 rN Lft64 C.s. m+ is .uea.A"wZ I FOR DEPARTMENT USE ONLY Application Accepted by 1 Date 1/ 1 Z L Area PN or Grout Inspection by Date a r`$ `� Final Inspection by A Date r� Additional Comments: Applicant - [return all copies to: San Joaquin County Public Health Services S� Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 tFEE AMOUNT DUE AMWNNT REMITTED CK 8 CASH 1VED SY r DATE PERMIT'NO. E.1124 IREV.I/e51 S& .� CJ�•� 73y� • Il �z1�7/ qZ-3�C8 EH 14.Ia r I