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.APPLICATION FOR PERMIT SAN JOAQUIN COUNTY' PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN* PHONE (209)468-3420 P 0 BOX 20090 STOCKTON, CA 95201 EMIT IRE YEAR FR D (Complete in Triplicate) ; Application it hereby areae to Sari Joaquin County for a permit to construct and/or install the work herein described. This plication is dii►dt in coftil ince with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Sei-vicei. Job Address C] ( ll��r�F'tfGL�1 City�a n Lot Size/Acreage /��X I.r� — + -- - u - — -r-__-- L- _ Owner's Noma Address &21 j 6-229,U Z),.roaa:�— Phone '1 1-A � Yl3 Contractor �x" /� Address f.I License No. �«*� + Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ but of Service Wel 0 PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well O 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing 171 Domestic/Privata ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications I'1 Public rl Other t-1 Delta Depth of Grout Seat Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Inslslled by Repair Work Done 0 Type of Pump H.P. State Work Done Welt Desenieii6h O W" Diatttatbt Sealing NdLterial i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 toot.) j Installation w"i carve: r Rnidenci— Commercial— Other J Number of living itnita: Number of bedroom! Character of soR to a depth of 3 feet: Water table depth SEPTIC TANK ❑ .Type/Mfg Capacity No. Compartments j PKG. TAWMENT DLT.0 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE .IV No. 6 Length of lines —_LCL 46' Zezi, Total length/size FILTER BED ❑ Distance to nearest: Well 1661 Foundation Ir�3 _ Property Lina .� SEEPAGE Pitt I I Depth AW 12_ _ Sire ' CIX�,�,., Number SUMPS LX Distahc6 to naarett: Well ` Foundation Property Line DISPOSAL PONDS, -o I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. !late laws. and j rule$and regulations of the Sen Joaquin County Home ownat of llcerlted agent's signature cartifiea the following: "I certify that in the performance of the work for which this permit is issued, I shall not omploy any parson ifs such rnannar is to become subject to workman's tompansation laws of California."Contractor's hiring or tub-Contracting signature certifies the followin8: "I eirtify thit in the performance of the work for which this permit is Wusd,I shall employ persons subject to workman's compensa- tion lawn 60 California." i The applicant ' it too for rn r nspdc s. Complete drawing on reverse side. Title: Data: --- FOR DEPARTMENT USE ONLY Application Accepted by Date a_ i Q Pit or Grout Inspecibn by Data Final Inspection by Additional Comments: Applicant - heturn all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services F 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 r FEE . AMOUNT D UE AMOUNT RECEIVED by DAT fRM1T'N0.INFO EN d-24IREV.riws) IN 14136E s If