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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ,445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE U (Complete in Triplicate) i Application is hereby glade 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 1 Joaquin County Public Health Services. Job Address - lam,l k City � � Lot Size/Acreage IAC Qom' GI-P Owner's Name e�7-1 Address _ - Phone Contractor � Address • icense No. Phoney TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT UA DESTRUCTION ❑ Out of Service ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Stell ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE \ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ MTEND g.USE f TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El lndustrialY ❑ Open Botiom IDManteca Dia. of Well Excavation _ Dia. of Well Casing sr [I Domestic/Privet* v " 0 Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public, Cl Other r;i Cl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by k k Repair Work Done 0 Type of Pump H.P. r l State Work Done _ Sealing Material i Depth } Well Destruction ❑ Well Diameter _ - # , Depth • A " r . ller Material. i Depth TYPE OF SEPTIC-WORK: ` NEW INSTALLATION. REPAIR/ADDITION DESTRUCTION 114 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence--k Commercial Other Number of living units: Number of bedrooms Character of Roll to a depth of 3 faet1 Water table depth SEPTIC TANK TypelMfy t L Capacity. No. Compartments PKG.-,TREATMENT PLT.❑ f 'L�� F , Method of Disposal Distance to nearest: Well foundation "l ._.Property Line Q '� LEACHING LINE ,lir. No. m Length of lines -5b t E Total length/size a FILTER BED _ ; G7 Distance oto nearest: well _ cb -Foundation - A/ Property Line A6 r SEEPAGE PITS 171 Depth Sire ' /�f• Number ' SUMPS Distance.to nearest: "'Well SB Foundation 1 a Property Lina /e DISPOSAL PONDS ❑ 1-1�� . V r I hereby certify that I have prepared thi's'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_ - -r-1 ' t ,. Home-owner or licensed agent's signature c_onifiis the following: '9 certify that in the performe worro performance of thk for which this permit is issued, I shall t employ any"parson in such manner as.to becaris.sutiject to workman's compensation laws of California." Contractor's hiring or sub,contracting signature ' certifies the following: "I certify'.ths6n the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califdmia: 'J 4 N The applicant rnust`tal r MI requiryd inspections."Complete drawing-on reverse side. y !� ` x i - Title: _ Date: Signed FOR, DEPARTMENT USE ONLY Application Accepted by `° r Date Area I I Pit or Grout Inspection by Date Final ! Inspection by Date Additional Comments: H Applicant - Return all co San Joaquin County Public Health Services + y vironmental Health Permit/Services `-,! A*94 an Joaquin, P O Hox 2009, Stkn, CA 95207 FEE AMOUNT DUE 1 AMOUNT REMITTED � ' ECEIVED BY DATE MIT'NO, INFO • EH 13.2411W.IINS) r+{> pQl' EH 11.20 Sim ` '.