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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES a ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PERM T EXPIRES 1 Y FROM DATE ISSUEDN 1 (Complete in Triplicate) Application. is hereby made to Ban 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. 51+9 and 1862 and the Rules and Regulations of San + Joaquin County Public Health Services. Job Address _ ;�(� � - 'City IIPy� Lot Size/Acreage ^,Owner'se* � _ � �Address gn Phone S Contractor ddress License No.'� Phone ' t TYPE OF WELL/PUMP: EW WELLt WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well 0 r PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE Tp NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.= PROP. LINE FOUNDATION AGRICULTURE WELL �y,� fELOTHER WELL � PITS/SUMPS L;U I INTENDEDUSE' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 177 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omastic/Private . Travel Pack ❑ Tracy Type of Casing__ d�l/C— _ Specifications /I"1vvPublic Cl Other fl Delta Depth of Grout Seal Type of Grout I I Ifrigation ';�.Approx. Depth l I Eastern $ rface Seal Installed by Repair Work Done 0 Type of Pump H.P., L` Statq Work Done �l Well Destruction ❑ Well Oiamater Sealing Material i Depth r loepth Filler Material i Depth i TYPE OF..SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION I i iNo septic system permitted if public sewer is F available within 200 feet.1 {nitalletion will servo:. .Residence Cotnmercii i - Other #, Number of living units:= Number of bedrooms x t t Water table depth f Character of soil to a depth of 3 feet: y _t No. Cam rtmenq i SEPTIC-TANK. - O ,_Type/Mfg _ Gpadty Pa G. TREATMENT PLT.0' � � Method of Disposal PK f off= Distance to nearest: Well Foundation Property Line `l + LEACHING LINE Cl No. A Length of lines 4 "'.Total length/size l FILTER BED ❑.-Distance to nearest:- Well t Foundation Property Line SEEPAGE PITS 1`1 Depth Sire Number 5 s SUMPS L1 Distance to nearest: Well Foundation Property Line ' DISPOSAL.PONDS ❑ ;g I hireby 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, 1 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 perlormance of the work for which,this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." i r !+ f The appliean o I requir a. Complete drowing'on reverse side. SigDate: Title: Date. '" FOR DEPARTMENT USE,ONLY - Z T Date Area� Application Accepted by fJ /"�j r "'" f - Pit or ro Inspection by rn�g �!�m ate �L Final Inspection by r Date Applicant - Return all copies to: San Joaquin County Public Health Service Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE • PERMIT"NO. " INFO , yy��N yry r� Yt�3 •-EFS Ii•241ttEV.'t)n61 'w ;1.3. 'gy m ��' /00 � 37 `//' .... fH iris f p