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APPLfCATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O SOX 2009, STOCKTON, CA 95201 (209) 468--3447 C/ REMIT EXPIRES I R PROM DATE (Complete in Triplicate) 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 Elan Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1(1 U214-C41 ,__ City Lot Size/Acreage Owner's Name16K` I� Address _. r R Phone Contractor NAddress License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well 13 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 s fl Industrial ❑ Open Bottom-" ❑.Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack �` ❑ Tracy �Typi-of Casing Specifications M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout C! Irrigation Appto�r, Depth ❑ Eastern ; x Surface Seal installed by � � "'� Repair Wprk Dons La Type of Pump .` H.P. State Work one Well Destruction A Well Diameter _1a�.r Sealing Material 4 Depth l Depth -_- - � Filler ]Material Y Aept'h *`b TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION Irl DESTRUCTION CI (No septic4ystem permitted if public sewer is ru available within 200 fest.) Installation will serve: Residence__ Commercial— Other f % Number of living units: Number of bedrooms � Character of soil to a depth of 3 feet: l� ' Water'.table depth �} SEPTIC TANK. ❑ Type/Mfg Capacity_ .---,-^-`No. Compartrtients PKG. TREATMENT PLT.0 _, ,,,,_„ Method of Disposal Distance to nearest: Well Foundation Property Line C LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED [_I Distance to nearest: Wall Foundation -e Property*Line SEEPAGE PITS I i Depth Size -y Number { i SUMPS LI Distance to nearest: Well Foundation � �'�. Property Line. i DISPOSAL PONDS ❑ 4 I hereby certify that I have prepared this application and that the work will be done in,a�,cordan'ce with San Joaquin county ordinances, state laws, on, i rules and regulations of the San Joaquin County -4 'A ; Home owner or licensed agent's signature certifies the following: "I certify that in the ps'rformance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to warkman's compensation laws of,California," Contractor's hiring or subcontracting signatu� certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons aublect to workman's compensa- Zion laws of California." - - The applican us requi ns. Complete drawing on raver 4lde. Signed Title' _ �li Date: _FQq DEPARTMENT USE ONLY Application Accepted by Date ._�Z cls_ Area Pit o►krAvInspection by Date [L72 `' Final Inspection by Date i Additional Comments; i 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 y IMFE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 3t�24iREV.r?Ktl %� EH 3 2a CT:)