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i APPLI CATI OAT FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION A A 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 Services. Job Address A01 cityZ/v` / Lot Size/Acreage I Owner's Name r �& f Address Phone/ g� �J�t .�� fl� � ..L_L l" Phone G/ Contractor /�©U�e'�/ l «� Oddress e .,� License No. TYPE OF WELL/PUMP: NEWWELLX WELL REPLACEMENT ❑ DESTRUCTION 5 Out of Service well O PUMP INSTALLATION_O SYSTEM REPAIR ❑ OTHER O Monitoring well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Z DISPOSAL FLO. PROP. LINE ��``1 I FOUNDATION AGRICULTURE WELL a OTHER WELL 'PITS/SUMPS/� . I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial O Open Bottom O Manteca Dia. of Well Excavation f e Dia. of Well Casin �� l Domestic/Private O'Gravel Pack O Tracy Type of Casing_ Specifications \ I'1 Public Cl Other n Delta Depth of Grout Seal 1/6 Type of Grout lllrrigation Approx. Depth I I Eastern Surface Seal Installed by / f r 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 I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 1 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. O Method of Disposal Distance to nearest: Well Foundation Property Line j LEACHING LINE O No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O f i 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 t rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicap at callal squired inspections. Complete drawing on r se side. Signed Date: R DEPARTMENT USE ONLY � �1QJ Application Accepted by Date r5- ,3 C n 13 'Area 02 k` '"► Pit Z�AGrout IIapection by Date Final Inspection by Date_ Additional Comments: crr 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 INECK 11 AMOUNT DUE AMOUNT REMI ED CASH ECEIVEO BY DATE PERMIT'N0. t ^� . EH 13-24(REV.��ws1� `'� �� `d F• p EN 11.71 ` CJ — -s,•