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At APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201. (209) 4683447 PERMIT EXPIRES 1 YEAR ISR M DATE ISSUED (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 trade in compliance with San Joaquin County Ordiq&pce o. 549 and 1862 and the Rules aad Regulations of Ban Joaquin County Public Health Services. ��j �� .+ /rJ�' Job Address 4 0 , City Lot Size/Acreage Owner's NameZ"7_wa—_7 Ad r Phone A, Contractor Address ! License No./ Phone Q I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN [l DESTRUCTION 0 out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ID Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE v FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� /�� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L/ C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public is Other ❑ Delta Depth of Grout Seal Type of Grout ci Irrigation —Approx. Depth d Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction O Weft Diameter Sealing Material i Depth I Depth ller Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIRIADDITION M DESTRUCTION CI (No septic system permitted if public sewer is f"10' available within 200 feet.) Installation will serve: Residence— Commercial Other Number of living units: Number of badroo s _ 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfo )2!� - - Capacity No. Compartments PKG. TREATMENT PLT. C1 ] Method of Disposal �J� Distance to nearest: Well IAL_ U _ Foundation Property Line .'3 LEACHING UNE ❑ No. & Length of lines Total length/size____ 12 FILTER BED CI Distance to nearest: Well Q_._ Foundation Property Line r SEEPAGE PITS l I Depth :e Number _ LI Distance to nearest: Well ~ Foundation ._ Property Line D19—P-0—SAL 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 following: "I certify that in the peiiormance of the work for which this permit is issued, I shall not amploy 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 certify 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." F The applicant must call for all qui spections. Comps s drawing on reverse side. Signed Title: Date: ILI Z r F fi DEPARTMENT USE ONLY .4 Application Accepted by cam►., 14 'SE.� f.�,.'�� - --- Date n a Pit or Grout Inspection by Date Final inspection by Data Additional Comments Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2049, STOCKTON, CA 85201 CK FEE INFO AMOUNT rDUE AMOUNT REMlT'TEO CASH FiECOVEO 9Y DATE PERMIT'NO. . EH -24 iREV.1iNSiAi\� r�Q (� �� q I EHA-211 13.E