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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 j � C6'D 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 vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services Job Address eo lo.3 A . City Lot Size/Acreage UASa Na dress Phone i^ V:O �g t Con rWcor dress I se No. hone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMEN C) DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION SYSTEM REPAIR O OTHER O Monitoring Well O 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 gustrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing mestic/Private O Gravel Pack ❑ Tracy Type of Casing_. Specifications lic Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Dep I I astern urfaee Said Installed by Repair Work Done U Type of Pump H.P. State Work Obi Well Destruction ❑ Well Dia r Sealing Material i Depth Depth �t Filler Material i Depth R TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) 1$" Installation will serve: Residence_ Commercial_ Other f i) Number of living units: Number of bedrooms v� Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1' PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, am rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Cal' nis." The applic t t call for inapt) tion$. Complete drawing on rev side. r gig Title: Date: !/ A/ O DEPARTMENT USE ONLY Application Accepted by 13 A A A Date Area Pit or Grout Inspection by Date Final Inspection by Date 1 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 AMOUNT DUE AMOUNT REMITTED K RECEIVED 9Y DATE PERMIT'N0. INFO (CASH . EN1Y211REV.tift51 ^rO/� AI�rf?D lisy�� til\ 3-44 , EH 1426