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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIRESS 1 YEAR PROM DATE ISSUED . UI/ (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 San Joaquin County Ordinance No. 549 and.,1862 and the Rules and Regulations of, San Joaquin County Public Health Services. Job Address �r �S � 0 � CityLot Size/Acreage L 4e_G . Owner's Name� M, La 1 C"1 1> Address I -5 d�! ��9Y� f=[2 0 _ Phone Contractor f Address V t '9N1 "1 �-License Ne��e3 Phon ' TYPE OF WELL/PUMP: NEW ELL O WELL REPLACEMENT ❑ DESTRUCTION O Otut pf.1ServicelWe7 l I PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial- O Open Bottom- Manteca— Dia:-of-Well•Excavation -- ----.--. --- _,Dia. of Well Casing LJ Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications M Public Cl Other IO Delta Depth of Grout Seal Type of Grout Cl Irfioation Approx, Depth O Eastern Surface Seal Installed by t_ Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material & Depth (� Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence.. Commercial` Other r Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK O Type/Mfg � ` Capacity "L No. Compartments PKG. TREATMENT PLT. Q - � f Method of Disposal Distance to nearest: Well .y Foundation Property Line LEACHING,LINE O No. & Length of lines Total length/size FILTER BED n 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 O I hereby certify that 1 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 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 workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "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 laws of California." The applicant must call for all require inspections, Complete drawing on reverse side. � Signed(�1� /I A 4,Q Title: SC� Date: f I FO EPARTMENT USE ONLY `�j`T Application Accepted by - Date `�—� �� Area Pit or Grout Inspection b > .�j-L Date ,� Y Final I spection by Date Additional Comments: _ _, -- - _, _ . . .. Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI ES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH I RECEIVED BY I DATE PERMIT NO. :� EH 13.24 IREV.1/8 51