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APPLICATION FOR PERMIT 'Z,�e p-9 Z 'Ifs 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 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. i t Size/Acreage ) Job Address 7 Cityddfd� iD �v Owner's Name �° los Address Phone ` 1 j 1 Contractor �..ress License No. �v Phone 22 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION O Out of Service well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLO. It- PROP. LINE FOUNDATION AGRICULTURE W L OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA Co TRUCTION SPECIFICATIONS O Industrial O open Bottom O Manteca f Well Excavation Dia. of Well Casing F1 Domestic/Private ❑ Gravel Pack O Tracy of Casing_ Specifications ('1 Public Cl Other n Delta of Grout SealType of Grout I I Irrigation —Approx. Depth I I Eastern ce Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sower is fit} available within 200 feet.) Installation will serve: Residence ✓ Commercial ther Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: 4 Water table depth SEPTIC TANK. O Type/Mfg s1 Capacity. No. Compartments ` PKG. TREATMENT PLT.❑ Method of Di l iL Distance to nearest: Well= Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines yd Al;lr-- Total length/size a FILTER BED O Distance to nearest: Well Foundation Property Line \� SEEPAGE PITS 11 Depth Size ZXI Nmmber SUMPS LI Distance to nearest: Wall 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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 at call required ' spectlons. Complete drawing on reverse side. Signed Title: �� Date: / /./ I- FOR DEPARTMENT USE ONLY Applicat Accepted by Date Area C Pi or Grout Inspection by Date Z Final Inspection by Date 9 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 Ne FEE AMOUNT DUE AMOUNT REMITTED I K S RECEIVED BYATE PERMIT'N0. IN O EEH 13.24(REV.r/M 5) H 14•�a a