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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE S d� (Complete in Triplicate) Application is hereby glade to S&WJoaquin County for a permit to construct and/or install the work herein described. This application is made in coatrpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. )rjob Address Lot Size/Acreage 1tAA f% Phone wner's Name 1 Address I Contractor Lr 1 q� *�— --Address License No, Phone t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. ^. PROP. LINE FOUNDATION GRICULTURE WE OTHER WELL PITS/SUMPS " INTENDED USE TYPE OF WELL PROBLEM A CO TRUCTION SPECIFICATION L-1Industrial ❑ Open Bottom C1Manteca ia. of Well Excavation_ Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack '❑,Tracy Type asing_ Specifications I"1 Public !-1 Other ' 19-veltaa T^{ Depth of Grou I Type of Grout I I Irrigation ^.AMox. Depth I 1 Eas n t Surface Seal Installed by Repair Work'Done"0 Type of Pumf H.P.r State Work Done _ y' Sealing Material i Depth D Well estruction` ❑ Well.Wiameter, Tiller Material i Depth t� Depth TYPE Of SEPTIC,WORK;. NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sower is r- s available within 200 feet.) 11 ' L Installation wiii•servs: ''�eiid"ence� Commercial^ Other Aso_= �f � � /Number of living units. _ �Number of bedrooms �j[Character of soil to a depth of 3 feet: I Water table depth SEPTIC TANK. ❑ TWe/Mfg'• Capacity 1 �� No. Compartments PKG. TREATMENT PLT. ❑ 'r L I Method of gisposal ��SS M Distance 47niearest: Well SD Foundation Ian - Property Line w 1 - LEACHING LINEN No. 8 Length of linea fatal length/size FILTER BED ❑ Distance to nearest: Well Foundation U__— Property Line k SEEPAGE PITS A4 Depth Size_ 3�' ONumber I SUMPS Ll Distance io'nearest: Well Foundation Line .i DISP05AL PONDS O '"f � ereby certi}y Mat I Have prepared ifiiti application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and ragulatiorls of the San Jwquin County �-F Home owner or licensed agent's eignaturs certifies the Iollowing: 'i I certify that in the performance of the work for which this permit is issued, I shall not empk)y any person in such manner as to become subject to workman's compensation laws of California," Contractor's Ening or sub-contracting signature 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 laws of California." The appl t ust wll fo t r wired inspections. f omplate drawing on reverse side. I �i% t r a Al. Title: _().�7hf P-� _ Date: FO EPARTMENT USE ONLY A icstion Accepted by Date Area �- �-�, _ P o►Grout Inspection by Date Final Inspection by a Additional Comments: Applicant- Return all copies to: 8L Joaquin County Public Health Services Environmental Health Permit/Services G 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 h FEE AMOUNT DUE AMOUNT REMITTED CA 14-M S RECEIVED BY DATE PERMIT N0. INFO J . EH (REV.rir*s� 0� 4_7 Ek 147a - --.