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Aor APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH `SERVICES r , ENVIRONMENTAL HEALTH DIVISION�- P O BO% 2009, STOCKTON, CA 95201 �f r (209) 468-3447 C/ # PERMI:[ EXPIRES 1 YEAR ?_ QM PATH IS�5 (Complete in Triplicate) Application is hereby mdde,to San Joaquin County for a permit to construct and/or install the work herein described. This application is merle in compliance withrSan Joaquin County Ordinance No. 549"and 1862 and the Rules sad Regulations of San Joaquin County Public Health Services. -Job Address -Z eLL .S, � �T�^e e City oC�'7C�n Lot Site/Acreage /-- ''Owner's Name Address �' STZC n/Phone *"' Contractor CDS ddress PSZ-` fll icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INCATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD PROP. LINE FOUNDATION GRICULTURE WELL 0TH L PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM A CONSTRUE PECIFICATIONS f_l Industrial ❑i Open Bottom ❑ Manteca all Excavation Dia. of Well Casing _❑ Domestic/Private 0 Gravel Pack- ❑ Tracy • Type a &sing Specifications Q � ED Public f-1 Other 0 Depth of Gro Seal Type of Grout M Irrigation Approx. De 0 Eastern Surfaca Seal Insta by Repair Work Done LJ. Type of Pump H.P, to Work Done Well Desiruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material !e Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIWADDITION 0 DESTRUCTION CI {No septic system permitted if public sewer is + available within 200 feet.! Installation will serve: Residence_ Commercial— Other /. Number of living units: Number of bedrooms _ �J Character of,soil to a depth of 3 feet: �r Water table depth SEPTIC TANK. ❑ Type/M/g`` I��J� C "•c,"cTe IGapacity�:�D� 64L No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposel Distance to nearest: Well / 0-r Foundation j Property Line -- t.r LEACHING LINE r,` L� No.,& Length af'lines. Total length/si:e � + FILTER BED f:1 Distance to'nearest74- Well /0b-f- Foundation�— Property Line �S / SEEPAGE PITS of I Depth _ '"----size Sire _ _ �/ - Number 13 SUMPS LI Distance to nearest: Well CD- - Foundation ZjC--t--_ Property Line / DISPOSAL PONDS ❑ I hereby cenify'that l 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 cenifies 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: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa• tlon laws of California." ? , rhe applicant must cell for all required inspections, Complete drawing on reverse side. Signed Title: ®uP�> � �C <.rr + ]� __._ Date: /d;Za1., FOR DEPARTMENT USE ONLY r. Application Accepted by Data 77- �/ q. I Pit or Grout Inspection by Data Final Inspection by Data "� Additional Comments Ila Applicant - Return all copies to: SAIV JOAQUIN COUNTY PUBLIC REACTS SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES �°'t 445 N SAN JOAQUIN, P, O BOR 2008, STOCKTONJ CA 95201 �. S r r FEE AMOUNT DUE AMOASH RECEIVED 8 Y UNT REMITTEDi CDATE �f?ERMIT NO. d�j INfO `� � .. i Ear t7-ZIIREV.iina�