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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT EXPIREk IYfAR ?M DATE IISSUED (Complete in Triplicate) 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 conplia.nce with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name Address Phone ` 1Y -2LO Conlraitor Address r�Z�- xi.nse 10 hone TYPE Of LL/ UMP: NEW WELL Cl WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well C1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Die, of Well Excavation pia. of Well Casing U Domestic/Private C] Gravel Pack 0 Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal T p Type of Grout CJ Irrigation —.Approx, Depth ❑ Eastern Surface Seal Installed by r } Repair Work Done U Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION G (No septic system permitted it public sewer is l available within 200 feet.l Installation will serve: Residence— Commercial Other_arzz Number of living units: Number of bedrooms Character of twit to a depth of 3 fees: water table depth SEPTIC TANK. ❑ Type/Mfg -- ___ 124=:S, Capacity No. Compartments PKG, TREATMENT PLT. 0 Method Qf Disposal } Distance to nearest: Well f---= Foundation- LE oundat on Property Line LEACHING LINE ❑ No. & Length of lines 0 Total leng`thlaize12 FILTER BED n Distance to nearest; Well�� Foundation AD Property Line SEEPAGE PITS ( I Depth Size Number SUMPS LI Distance to nearest: Well Foundation `y Property Line DISPOSAL PONDS ❑ "' I hereby.cartify 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I canify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for ail requ flrin pections, Co ,plate drawing on r erse side. ` Signed Title: Date: R D MENT USE ONLY Application Accepted by Is- Date 3 ~�S Area Pit or Grout Inspection by Dat Final inspection by Data 3 Additional Comments: 2f Applicant – Rotors all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201.FEE i INFO AMOUNT DUE AMOUNT REMITTED ASH CK if RECEIVED BY DATE PERMIT NO. . EH 13-211rrEV,t/n Sr fyi E!1"41.210W