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APPLICATION FOR PERMIT .-3 � / SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 " P O BOX 2009, STOCKTON, CA 95201 ..PERMIT EXPIRES 1. YEAR FROM DATE ISSUED j (Complete in Triplicate) Application-in hereby made. to.8aa Joaquin County for a permit to construct and/or install the work herein described. This application is made in cowpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /� _ � � a Job Address rla"i t•+ �'I• 44&' `SIX "��A/ City &IwC Size/Acreage n p ' Owner's Name W hA04MPAMAddress?0e O &A-- Phone II TP Contractor Address Ce No/�_ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 4 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS INTENDED-USE — r_ TYPE-OF-WEL-L� PROBLEM-AREA -CON STRUCTION.SPECIFICATIONS -•--.w Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing L.1 Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications s ['1 Public f.1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation 'Approx. De th l 1 Eastern urfaca Saul Installed by Repair Work Done lk Type''W Pump�� iE H.P. State Work Done Well Destruction 13 Well Diameter Sealing Material-i Depth ^, M Depth ]filler Material i Depth f TYPE-OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is k available within 200 feet.) 4 Installation will serve: Residence_ Cornmercia Other Number of+ving units: —=•��-Number ofbedrooms- -- Character of sol}to a depth of.3 feet: Water table depth +} ! 1 SEPTIC TANK. O :Type/Mfg Capacity No. Compartments Il PKG. TREATMENT PLT, Gl I� Method of Disposal Distance to nearest: Well Foundation Property Line I� 41 LEACHING LINE C1 No. & Length of lines Total length/size C FILTER $EO ❑ Distinca to nearest: I ' Founds Property Line SEEPAGE PITS i I Depth Size Number SUMPS LI Distance to nes t: Well Foundation Property Line DISPOSAL PONDS ❑ 11' 1 hereby certify that I have prepared this application and that the work will fie 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 compe4sation laws of California." Contractor's hiring or subcontracting 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 compenss- tion laws of California." The applicant Aust call for all required insps�ctions. Complete �/drawing on7�revebrse side. Signed igma �v�,-''� Witte: y 'J'� _._._ Date: �� x E �� FO MENT USE ONLY I Application Accepted by Date Area 2 Pit or Grout Inspection by �'I Date Final inspection by Data 3 3 3 Additional Comments: !� I Applicant - Return al T copies to: San Joaquin County Public Health Services 4 Environmental-Health Permit/Services 445 N San Jbegtiin, P O Boz 2009, Stkn, GA 95201 I� INFO AMOUNT DUE AMOUNT REMITTED CK 8 CASH RECEIVED BY DATE PERMIT'NO. . EM 14-24 111Ev.FinykE9 �3 .3� EFS t4•ls I�