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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � r ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCSTON, CA 95201 E S PERMIT EXPIRES 1 Y FRB D T 1 (Complete in Triplicate) � E Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is McAe in cempliance with San Joaquin Cour y Ordinance No. 51+9 and 1$62 and the Rules sad Regulations of San Joaquin County Public Health Services. ��n�� .5L I y.. .j, I S4 J�/3 I ;Cfi6��J City SLot Size/Acreage Job Address I` [ C_ I dress Phone &&L Owner's NameD a! Phone Contractor � Address 3 � License No. TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLAC ENT ❑ DESTRUCTION ❑ Out of Service Well OTHER 11 monitoring Well O l/ PUMP INSTALLATION ❑ SYSTEM REPAIR _�___�� DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �^ FOUNOATION AGRICULTURE WELL OTHER WELL PITS/SUMPS C� ` INTENDED•USE� ----TYPE OF-WELL— P_ROBLEM-AREA-CONSTRUCTION SPECIFICATIONS Dia. of Well Casing f ❑ Industrial ❑ Open Bo Gom ❑ Manteca Die. of Well Excavation Specifications.. - I E Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' f'l Public fl Other fl Delta Depth of Grout Seal Type of Grout r I I Irrigation Approx.' Depth 1 i Eastern Surface Seal Installed by Repair Work Done L1 Type of Pump H•P• L.S" State Wor�Qe We"Destruction O Well DiameterSealing MaterDepth ial i Depth 1Mller material $ Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Fl Installation will serve:f Residence_..._ Commercial Other Number of living units: Number of bedrooms M Water table depth j Character.o!soil to A depth of 3 feet: SEPTIC TANK. ❑ Type!q Capacity No. Compartments PKG. TREATMENT PLT.❑. I Method of Disposal . ., Distance to•nearest: Well Foundation Property Line LEACHING LININ Cl Na. d Length of lines Total lengthlsize FILTER BED ❑ Distance'i nearest: Well Foundation Property Line ! I SEEPAGE PITS I I Depth Size Number SUMPS LI Distance)to nearest: Well Foundation Property tins 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 Iowa, and rules and repulatiorta of the San Joaquin County Homs 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature r certifios 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 Iowa of California." III The applicant must catt for all required inspections. Complete drawing on reverse side. 941192 --- Signed Title: ' Date: I �FOPARTMENT USE ONLY Z— Application Accepted by Date Area I. �P' Date Final inspection by Date Pit or Grout Inspection by # Additional Comments: I� i Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ' 445 N San Joaquin, P-O Box 2009, Stkn, OA 95201 f'f RIN AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. ( { . EH13.24(REV.1yN61 . FH 14-38 � � '