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APPLICATION FOR PERMIT � �v SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION + 1601 E. HAZELTON AVE. , PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PEMIT EXPIRES 1 YEAR TSR M DATE MU (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This 14 application is amde'ia compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f S9 17 City S�^/ Lot Size/Acreage jyS7C boa Job Address • Phone t Owner's Name Address Contractor f ' Address .�- ��- �� License No. �4 hone -P of Service Well Ll TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M_ DESTRUCTION ❑ Out ' r OTHER 13Monitoring Well 0 PUMP INSTALLATION ❑ f SYSTEM REPAIR L] DISPOSAL. FLD. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PROP. LINE FOUNDATION • AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well-Exca'Vatiorti Dia. of Well Casing f_l Industrial ❑ Open Bottom ❑ Manteca e _ fl Domestic/Private ❑ Gravel Pack ❑ Type of Casing-9- Specifications ("1 Public l l Other F1 Delta Depth',of Grout Seal _Type of Grout !, I I Irrigation Approx. Depth L I Eastern Surface:Seal Installed by Repair Work Done 0 Type of Pump H.P. f State Work Done Well Destruction ❑ Well Diameter Sealing Material'& Depth Depth Filler Material h Depth , TYPE OF SEPTIC WORK: ,NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I 1 iNo septic system permitted it public sewer is c r available within 200 feet.) Installation will serve: laesidence Commercial_ Other Number at living units: __J_ Number of bedrooms Character'.of soil to'a depth of 3 feet: _ LA y _Water table depth SEPTIC TANK. ❑ TypelMfg 45z2t S 1-1AJG_ Capacity 4 No, Compartments PKG. TREATMENT PLT. ❑ 1.11 F� " h Method of Disposal � E Distance to nearest: Well FoundationrProperty Line LEACHING LINE LOKN,. & Length of line's. Total length/size 42' FILTER BED 0 Distance to nearest Well aD� Foundation _ 3�- P, rty Line k t SEEPAGE PITS I Depth _ so"i- �- _-Size n Number � r , SUMPS L1 Distance td-,nearest: Well- / Foundation C�t 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 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 sub-contracting signature certifies the following:"I certify thot'in the performance of the work for which this permit-is issued, l-shall,employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections, Complete drawing on reverse side. SX G .[✓ _ le: -Date: Signed Tit /7— FOR DEPARTMENT USE ONLY S Ap lication Accepted by ,, Area Pit r Grout Inspection by"-'' " ` `T�� Data Final Inspection by �'-"``"-'^� Dat fir. Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health s� ,�_.. - -r.--� • --Services-, Environmental-Health•Permi.t/Services 1601 E. Hazelton Ave., p 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCASM RECEIVED BY DATE PERMIT'NO. INFO M� EM 13-24 IREV.I/K!,) Se. 1)I oU Iy,°� ^ m [ . iCk I EH 7l-26 J