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APPL I CA' I ON FOR PERI[I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1 � P O BOX 2009, STOCBTON, CA 95201 (209) 468-3447 J2ERMIT EMIRES 1 YEAR PROM 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 Services. _ ,, -4—.Z&J_ 7Z� 1 t J/l/ City �� L Lot Size/Acreage Job Address .�. _., r- Owner's NS s . � (1&---= 6�� ssPhone Contractor Addres�� oo Phon TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 0 DESTRUCTfON O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well [3 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 0 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications M Public Cl Other 0 Delta Depth of Grout Seal Type of Grout . U Irtioation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION X, DESTRUCTION G INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence� Commercial_ Other Number of living units: .1Number of bedrooms S / `/ Character of soil to a depth of 3 feet: Water table depth �✓ .. SEPTIC TANK FK1S7_0 Type/Mfg r� �` Capacity L No. Compartmsnta PKG. TREATMENT PLT, CI Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED Distance to nearest: Well 1^ Foundation—/40 :f-- Property Line — (Q`X SEEPAGE PITS I I Depth Size Number SUMPS Ll 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, 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, I shall not employ any person in such msnnsr 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 California." The applicant must call for all regwred inspe tions. Comp) drawing on rever e. g Si ned Title: fS` ,�_ Date: '' I FOR DEPA TMENT U ONLY Application Accepted by _r_____�" �'C�r� CSS ` c O DatArea 2 f Pit or Grout Iniaptiction by Date Final Inspection by ! ! Date s 51 ' Additional Comments:' t t S ��Q A S OS ApplicaAl- Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT'NO. INFO l.� l CASH I� L� q . EH13.24IREV.iin51 �� C " \.00 - 1 ' 1' 8 gIto /✓ / 22 / ��D� EH 1140