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APPLICATION FOR PERMIT 144 4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ��6j,�0�le,� ENVIRONMENTAL HEALTH DIVISION AP � P O BO% 2009, STOCKTON, CA 95201 S R 1 j (209) 468-3447 P re I" ,S r of ENV�R M H�4�rN c��NTy I naIT A (Complete In R PROM AT ISSUR ONTg4H1�rr-yv1�'e5 �/V/S;;: Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Cit Lot Size/Acreage Q Owner's Name Address t_� L�� e � PhonegZ2y Contractor 4gjw Address License No,7 [!—Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER R1 Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing s Q� Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications 1 1.0 Public EI Other ❑ Delta Depth of Grout Seal Type of Grout ; r { MI Irrigation —.Approx. Depth 1=1 Eastern Surface Seal installed by Repair Work Done Type of Pump a s H.P. ___ _ State Viork Done Well Destruction ❑ Well Diameter Sealing Material &. Depth A .(- Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIRIADDITION M DESTRUCTION 1=1 (No septic system permitted if public sower 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 feel: n Water table depth ' SEPTIC TANK. ❑ Type/Mfg Capacity_.- No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. &-Leneth of fines' - "' Total"{engin/size""—'-"`" '-,.�-.`- '�,- FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number ; SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS I hereby certify that I have prepared-this application and that the work will be done in accordance with San Joaquin county ordinances;estate sews, 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 workmen's compensation laws of California," Contractor's hiring or sub-contracting signature ' certifies the following: "I certify that in the performance erformce of„the work for which this permit is issued, I shad employ persons subject to workman's compensa- tion laws of California... lj . The applicant must call f all required inspections. <ramplete drawing on re arse side, ! / Signed X -r^ Title: t� Date: �/ / 2Z FOR DEPARTMENT USI” ONLY Application Accepted by Date A ' < Pit or Grout Inspection by 'Date Final Inspection by ` D its Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOR 2009, STOCKTON, CA 95201 INfJ/FEE Q;] AMOUNT DUE AMOUNT REMITTED ASH (RECEIVED BY DAATTE+'/J PEA MIT'NO. . Ell 1374 Il1tEV,i r n>> EN^,{•ia , iii ✓✓✓ ..