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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT. EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is smde in cotiliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public He h Services. Act AJob Address City Lot Size/Acreage Owner's Name Y y 0 Address l��` "�ala J-�Pe Phone Xcontractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER Lt ES DISPOSAL FLD. PROP. LINE FOUNDATION AGR E WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C0 TRUCTION SPECIFICATIONS Q Industrial ❑ Open Bottom ❑ Manteca Dia. of U_�Nlcavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 11 Public Cl Other 1'1'Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDiT10N I I DESTRUCTIO o septic system permitted it public sewer is = Nevailable within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms ` Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments ) PKG. TREATMENT PLT. ❑, Method of Disposal - 'Distance to nearest: Well Foundation Property Line 11 t LEACHING LINE Cl No. i Length of lines Total length/size D FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Homs 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 of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for oil required insPections. Complete drawing on reverse side. (Signed X Title: 5,� f 1 e Date: Y. FOR DEPARTMENT USE ONLY Application Accepted by l" Date q + Area Cif Pit or Grout Inspection by ]]Date Final 1Inspection by G Date Additional Comments: (4�G1—.5 5�[✓ Applicant - Return all copies to: Ban Joaquin County Public Health Services Environmental Health Permit/Services 445 N San .Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH-- RECEIVED BY DATE PERMI7'NO. . EM 13•I4 IItEY.t '01 '7q '6f Q 0 EN t�•26 rx r