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APPLICATION FOR PERMIT 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 ISSPED M (Complete in Triplicate) Application is hereby atade.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in eoWliartce with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. k Job Address — � 3 �� ' � -- -- City GCi 1 Lot Size/Acreage Q.,4 "- - Owner's Name t'!L� �{ cyc . 0 - Address �-'�Y?'.� Phone 671 r Contractor t-? Address ~ License No. )3 Phone_l - TYPE OF WELL/PUMP: "" NEW WELL ❑ +• W_ ELL 1EPLA )ENT C❑ DESTRUCTION ❑ Out of Service Well Gl PUMP INSTALLATION ❑ �- r C SYSTEM REPAIR.❑ OTHER ❑ Monitoring Well 0 I DISTANCE TO NEAREST: SEPTIC TANK SEWERLINESDISPOSAL FLD.—, PROP. LINE FOUNDATION AGRICULTUAEWELL OTHER WELL PITS/SUMPS :I w INTENDED USE TYPE OF WELL PROBLEM AREA CONS AUCTIONISPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r Cl Domestic/Private ❑ Gravel Pack 0_7 I a 177 Type of Casing_ Specifications i°l Public I71 Other c n Delta Depth of Grout Seal Type of Grout I I Irrigation _._._Approx. Dspih `I I Eastern Surface Seal installed by �.. Repair Work Done �❑ Type of Pump H,P-. State Work Done_ Wolf Destruction 0 Well Diameter Sealing Material i-Depth Depth Piller Material (.•Depth - TYPE OF SEPTIC WORK: NEW INSTALLATIONTI REPAIR IADDITIODESTRUCTION�I I INo septic system permitted-if public sewer is It- available available within 2(0 feet.) Installation will serve: Residence, Commercial_�__ Other I Number of living units: _* Numbed of bedrooms Character of soil to a depth of 3 feet' Water table depth SEPTIC TANK . ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Ll q Method of Disposal D Distance.io nearest: Well Foundation Property Line LEACHING LINE } No. b Length of fines (on-e_ Total length/size FILTER BED ❑ Distance to nearest: Well Ir 'Foundetion h f Property Line --- ', SEEPAGE PITS Depth Sire umbar SUMPS Distance to nearest: Well Foundation r 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, state laws, and rules and regulations of the Sen 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 compensation laws of California."Contractor's hiring or sub-contracting signature certifies the folowing: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Ism of California." _ P The applicant t telt for ail requir ions. omplete drawing on rev /side. Sig Title: -- /� � ,.. •—.._. Date: + OR DEPARTMENT USE ONLY � s Application Accepted by tAc Date '� Area v 5 I Pit Grout Inspection by Date Final Inspection by Date Ad ions) Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ` Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT 041E AMOUNT REMITTED K CEIVED BY __WE AEgMIT'NO. . EH Si"14(REV.r i n si / EH t4-71s