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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468— .t46�0 PERMIT BXPIRES 1 YEAR 98 A DATE IS511ED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This I application in made in.cotnpliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 0%7 za J-k City Lot Size/Acreage I r Q� l Owner's Name 10 Address- u p',190jC.. Phone 4 /:r Contractor Address ®� �' License No. Phone TYPE OF W L/PUMP. r. NEW WELL ❑x WELL REPLACEMENT E1 DESTRUCTION Out of Service Well Cl 5—i: PUMP INSTALLATION:_.0 . . . ._ .SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK n SEWER LINES DISPOSAL FLD.� � PROP. LINE " I FOUNDATION_ _AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications ❑ Public Il Other ❑ Delta Depth of Grout Seal if Type of Gro 0 IrriUadon _..Approa Depth 0 Eastern Surface Soul Installed by 1 iRepair Work Done U Type of Purr -t t H,P. Staie Work Done Material i Depth Well Destruction C7 Well Diameter Depth e r De TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADD I'q tvG TI J I o e is system permitted if public sewer 's d }..� 'I a within 200 feet.. .P sans may I d w. Installation will serve: Residence._ r Commercial therJ�P'� `. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I ` e� able depth SEPTIC TANK: ❑ Type/Mfg _ p No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line i i LEACHING LINE ❑ No. & of lines Total length/size FILTER BED Istance to nearest: Well Foundation Property Line i SE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will be done in accordance with San.Joaquin county ordinanc tato 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 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 Is o} The appli nt sl call for al eq spe ions. Complete drawing on reverse side: r --Iz- 9/ Signed Title: r.....A t".P_ Date:: . F DEPARTMENT_ USE ONLY Application Accepted by Date Area Ares Nj Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: — Applicant - Return all Copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O Bo% 2008, STOCKTON. CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PfRMlT NO. INFO r , CASSH EH 13-241Rev.IyKSI 1 f 1��00LvaL EM 14•211 VVdd i