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APPLICATION FOR PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1V8 WAI 0<AuA__ 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 Na 41C d< PERMIT EXPIRES 1 YEAR FROM DATE ISSUE (Complete in Triplicate) �ol �. �• Application 1s 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. `]� Job Address �I F� _ 7. ,! E City�-Tn&7° t Size/Acreage' J� Owner's Name 44n G/'Q 0 i d �m�ddress ��rn� Phone — Contractor se / Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O YSTEM REPAIR O OTHER O Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESN DISPPSAL FLD. PROP. LINE FOUNDATION AGRICULTURE LL HER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONST N SPECIFICATIONS L1 Industrial O Open Bottom O Manteca D' Well vation Dia. of Well Casing f:l Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ - Specifications Il Public Cl Other fl Del Depth of Grout Seal Type of Grout 1 I Irrigation Approx. Depth Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ 1 Well Destruction O Well Diameter Sealing Material i Depth I Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms m Character of soil to a depth of 3 fast: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. 6 Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS O 1 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 Horne 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 workmen'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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must 1 for all required inspections oma ete drawing on reverse side. igned T Title: Date: —Lo, f �— �\ FO EPARTMENT USE ONLY 2-11 Application Accepted by Ag, kA _ _ e._=Zftsmi; Data Area Pit or Grout Inspection by Date Final Inspection by 4qk Date 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 CK I CASH RECEIVED BY DATE PERMIT'N0. . EM M24(R&.r i h til EH 14-M