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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM 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 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Serv1 es. 4 Job Address City Lot Size/Acreage n is Na �� a IV_ t�x�cL�.7 JA's- s Phone `Q l Mt /y ►��i f(ss ?TZD a No^ RL� Phone TYPE OF WELL/PUMP: NEW WEL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR O OTHER O 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 L1 Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing ppmestic/Private ❑ Gravel Pack kL7 Tracy Type of Casing_ SpecificationsI'1 P__ubIic Cl Other n Delta De th of Grout Seal Type of Gr t I I Irrigation —Approx. Depth i I E ern /S ce Seal Installed by Repair Work Done U Type of Pump H.P. / State Work IQ ,�2-wi✓ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence_ Commercial_ Other 9 Number of living units: Number of bedrooms Character of loll to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well For ndation__T Property Line r LEACHING LINE CI No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth' Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 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 workmen's compensation laws of California."Contractor's hiring or sub-contracting!signature certifies the following:"I fy 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 C . The applican s cal ins , tions. Complete drawin on rev side. S' Ti e: Date: FO DEPARTMENT USE ONLY Application Accepted by AA u,A Date_�..�� ` _ Area d 2- t ' Ph or Grout Inspection by Date Final Inspection by Date q�- Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT'N0. . EM 1124 111EV.1/95) 9Z/n 5) Z 9 �7 EH 14.21 ` 1 1 fJ` t