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APPLICATION FOR PERMIT E-5SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION fV,0 LJ�/ ; P O BOX 2009, STOCKTON, CA 95201 J (209) 468-3447 PERMIT EXPIRES I FEAR k8QX DWER ISSUED (Complete in Triplicate) E Application is hereby mad! to San Joaquin County for a permit to construct and/or install the Work herein described. This application 1a tirade in cos�Iianca with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. ",Job Address �� Cit Lot Size/Acreage Owner's Name 2�1P �/�p�ddress _ � 470/ ,. r- .! Phone Contractor �� '�N Address /-- License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ Monitoring well C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Endustrisl ❑ Open Bottom C3 Manteca Dia. of Wall Excavation Dia, of Well Casing LJ Domestic/Private ❑ Giavel Pack 0 Tracy Type of Casing Specifications M Public CI Other C) Delta Depth of Grout Seal Type of Grout G Erngation �4prox, Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type pf Pump H.P. State Work Done_ Well Destruction D Well Diameter Sealing Material i Depth DeptO Filler Material i Depth TYPE OF SEPTIC WORK:. NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION !No septic system permitted if public sewer is �-~ Installation will serve: Reside!�nce._„ Commercial— Other available within 200 feet.) j Number of living units: Number of bedrooms �. Character of soil to a depthh-ofl3 feet Water table depth SEPTIC TANK •❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ a , Method of Disposal Distance to nearest: Weil Foundation Property Line LEACHING LINE Cl Noll Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Propeny Line 1 II ! l SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to nearest; Well Foundation Property Line DISPOSAL PONDS ❑ .11. 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 cenifies 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 a become subject to workmen'i 66mp6nsaiion laws of California." Contractor's hiring or sub-contracting signature canifies the follo ' . 1 Ge , in t performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- tion laws o alifornia." 1h The applics all req in ons. Complete drawin r er:a side. `P(Signed Tit, Date: l .iI FOR DEPARTMENT USE ONLY Application Acceptedby Date �V, �� t rea Final Inspection by Pit or Grout Inspection by Data �l k Dat � Additional Comments; 4' ru I Applicant - Returnall copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION pERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 INFO AMOUNT i)UE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. CASH • fHt�" IAEV,t��st —7y L lr(7 e i - G