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APPLICATION FOR PERI[I T S"J0AQUn9AXt Q UBLIC HEALT ERVICES ENVIRONMANWff AMIMDIVISION El ,RHONE (209)468-3420 sptM1JWKTON, CA 95201 to PERMIT-E%PIRP3 1 YEAR FROM DATIf I$SUIP (Complete in Triplicat57 Application is hereby made 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address u City Lot Si ze/Acreage Owner's Name r a i Address � /' ` Phone ContracAddress • `- License No. -?Z) Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION ===== '►GRICULTURE WELL OTHER WELL PITS/SUMPS T 'INTENDED USE TYPE OF WELL PROBLEM NSTRUCTION SPECIFICATIONS n Industrial Cl Open Bottom ❑ Manteca ort $Offr4VIAWasing ❑ Tracy ype of' *I�TTAL HEALT�i� USIGNcifications C7 Damastic/Private ❑ Graver Pack I"l Public I-1 Other Cl Delta De i (ult�e 4TCType of Grout I I Irrigation —Approx. Depth 11 tern Surface Soul lncu e yyi 11 �f - Repair Work Done ❑ Type of Pump H.P. State Work Done }(J1 Well Destruction O Well Diameter Sealing Material i Depth j Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIRIADDITION LLM&rTRUCTION I I INo septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence—L--Commercial Other SAN JQAQUIN COUNTY.PUBLIC NErILTH$ERyI Number of living units: . Number of bedr sI ENVIRON Character of soil to a depth of 3 feet: Water a DTVI IO SEPTIC TANK. ❑ Type/Mfg ` iNArm Csoacity �tma� PKG. TREATMENT PLT. ❑ L Method of Disposal w Distance to nearest: Well Foundation Property Line r • LEACHING LINE 0 No. 3 Length of lines Total length/size FILTER SED 0-�ncs to nearestWeil SO Foundation l� Property Line SEEPAGE PITS I I , Depth "Sire — Number �r SUMPS LI ..Distance-to nearest•t_ Well Foundation Property Lint! 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 fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in sural manner-as to become subject to workman's compensation laws of Californis." Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- n IwvI of Californ Thea t"bat II for r ui►s sp tions, amp drawing an averse side. `� Date: a l f l FOR DEPARTMENT USE ONLY Application Accepted by Date Area Z Pk or Grout Inspection by date Final Inspection by Data Additional Comments: T 7. Applicant - Return all copies to: San Joaquin County Public Health Services Ssvironmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMI7'NO. INFO // . EH 1IREV.I/h 6E 5 /! f / 1 EH t0l•39�