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r APPLICATION FOR PERMIT VICES SAN JOAQUIN MUNTY PUBLITH DIV g ON ENVIRONMENTAE[EALT]l SF L PHONE (209)468-3420 1601 E. HAZELTON AVE. ,CA 95201 p O BOX 2009, TXP RES 1 YEAR FR ) (Complete in Triplicate Rules and Regulations Permit to construct and/or install the work herein desc County fora pribed. This tions of San Application is hereby made.to San Joaquin lienee with San Joaquin County Ordinance No. 549 and 1962 and the application is made in campl-a I! � �. 2 7 I Joaquin County Public Health services. GLot Size/Acreage C; L_ �� fCr'.? 7 Phone 4� Job Address a `�� Address Owner's Name rA0 fr.-`l7 License No Address____�-�- DESTRUCTION Cl Out of service Well [l Contractor WELL REPLACEMENT ❑ Monitoring Well t7 NEW WELL © OTHER D TYPE Or WELL!_ PUMP! SYSTEM REPAIR ❑ PROP. LINE - -- -- PUMP INSTALLATION O DISPOSAL FLD.�-- SEWER LINES -- ----- OTHER WELL��-�-� PITS/SUMPS �- pSEPTIC TANK L--- ISTANCE TO NEAREST: FOUNDATION --- AGRICULTURE WELL � TYPE OF WELL PRQBL� EM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing INTENDED USE 0 Manteca Dia. of Well Excavation 5pecilications I U Open Bottom [} Industrial 0 Tracy Type of Casing Type of Groui i [I Domestic/Private C1 Gravei Peck Depth of Grout Seal 1:1 Other Cl Delta I'I Public Surface Seal Installed by I I i Public �_.APpro- Depth I I Eastern State Work Donis of Pump �_,- --- H.P. Repair Work Done L] Type Sealing yaterisi A Depth Well Destruction © Well Diameter Filler Material A Depth Depth available within 200 feet.} F SEPTIC WOflK: NEW INSTALLATION I k REPAIRlADDITION 4 I DESTRUCTION k I lNo sePti�stem permitted if public sewer is TYPE O A -a lnstaflation will serve: Residence _'YCommercial Other Q Number of living Unite: Number of bedrooms - Water table depth ? kyr '� Capacity- No. Compartme Character nts of soil to t+ depth of 3 feet: Method of Disposal SEPTIC TANK f TypelMlg. 55 Property Line -6/_ PKG. TREATMENT PLT, C1 Well !��- — Foundation --� Distance to nearest: Total length/940 5 / No. & Length of fines S- - Prape►tV Line LEACHING LINE Wetlj Foundation FILTER BED Cl Distance to nearest: %f Number �. ------- SEEPAGE PITS Depth Property Y Line p SUMPS . Distance to nearest: Well 9oundatian — slate laws, and DISPOSAL PONDS . certify that I have Prepared this application and that the work will be done in accordance ^"the work forSan trwhich this permin county ts issued, I shall not t hereby c Y rformance of the rules and regulations of the Sen Joaquin County 1 certify that in the Pe Home owner or licensed agent's signature canities the following:towing: persons subject to workman's compensa- rson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sup-contracting signs employ any Pe rlormence of the work for which this permit is Issued, I chap employ certifies the tollowing: -I certily that in the Qe tion laws of California." r all required inspaclions. Complete drawing an rev side. Dew.The applicant must call for Title: r i Signed X n FOR DEPA TMENT USE ONLY Z �f f i r Area L Date Application Accepted by Date Date��- Final Inspection by - - fl Pit or Grout Inspection by �,u yZ /� I�0�p J ^, rte `j� A � S 2 Tr Y Additional Comments: Public Health Applicant - Return all copies to: San Joaquin County Services, Environmental Heslox 2009. toc tces on, CA 95201 1601 R. RazeltOn Ave., P 0 Box 2009. Stockton, PER NO. CK RE'll by DATE FEE AMOUNT DUE AMOUNT REMITTED C 5H Y , (\IINFO I cN 13 24 InFV. I 4.?S