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APPLICATION FOR PERMIT 10 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT ERPIRAS I YEAR_ PROM DATE IS59ED_ (Complete in Triplicate) Application is hereby taade,to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in CoWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. Job Address '�-� City Lot Size/Acreage Owner's Name �'t'`� � Address Phone Contra c ddre La F��l e se �✓` -.�� Phony 1! TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT �❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR `L'f' OTHER 0 Monitoring Well 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 n Ind iei El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing =tic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications ❑ Public l-1 Other ❑ Delta Depth of Grout Seal Type of Grout 0 Irrigation y`/ Approx. Depth 0 Eastern ISurface Seal Installed by Repair Work Done flr7" Type of Pump/1 , •si_ H.P. I State Work Done �} Well Destruction O Weil Diameter Sealing Material & Depth V1' Depth Filler Material 6 Depth A, TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION C1 DESTRUCTION G 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. ConP"(AENT PKG. TREATMENT PLT. 0 Mothodal FOINVE Distance to nearest: Well Foundation Property Line .�.�13Z - 113 3 L LEACHING LINE L1 No. A Length of lines Total length/size rANI 10AQ1 IIN C.O.LiNTY FILTER BED n Distance to nearest: Well Foundation Propertf Ufi L. HEALTH SERVICES —___--- •-. ENVIRONMEN�ALTH DliriS ON SEEPAGE PITS Il Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby cenify that-l-have-prepared-this-application and [hat_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 shall employ persons subject to workman's compensa- tion laws of California." The applicant li f II require¢-in ctions. Complete drawing o re erre side. Signed X—. .. __ _ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Data. 7- Z - Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT AEMITTEO CASH K 4 RECEIVED BY DATE PERMIT'NO. . EH 13•24 rREV.iiNst P� toI � 0 0 J Z&Z,� Z_ EH-M /