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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES w ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , 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 is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Sery ces. Job Address City ` Lot Size/Acreage Owner's N. L '` Address �/�1/ ",'Odd if Phone QQ ,, c s7 6 z Contracto dress PC CX, I`/�7 Z� License No. Phone_ TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION Ii9— SYSTEM REPAIR ❑ /OTTHHEp C3MonitoringWell ❑ DISTANCE TO NEAREST: SEPTIC TANK Z00 / SEWER LINES DISPOSAL FLD.G -V-PROP. LINE FOUNDATION _k,01 AGRICULTURE WELL OTHER WELL,3p� PITS/SUMPS _V10 fe INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it tr n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 34-V6mestic/Private Wel5rivel Pack ❑ Tracy Type of Casing Specifications i'I Public (.1 Other n Delta Depth of Grout Seal / Ty of Grout I I Irrigation Approx. Depth I 1 astern Sr if ce Seal Installed by Repair-Work Done U Type of Pump H P. ! �3� S ork Don Well Destruction_ ��Well Diameter Sealing Material & Depth Depth Filler Material & 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 Number of living units: Number of bedrooms Character of soil 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 Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ID Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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 J Homeowner or it 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 on in such me eras to become subje to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies th ollowing: "1 certif hat in the ce f the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion law of California.' The ap licant m t call all re ti om ete drawing on r,&-,. Signed Title: A��_�Date: Of;eQ— / 4 FOR RTMENT USE ONLY Application Accepted by R� Date Area Pit or Grout Inspection by -2 Date Final Inspection by Date Additional Comments: i `� �� 7�7vyyd"✓� C' _ Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services �/� 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 / 0 FEE K I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. 2 IL:fff 2 0 G EM 13. EH n4.