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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)4583420 P 0 BOX 2009, STOCKTON, CA 95201 _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby, aside to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San - Joaquin County Public Health Services. Job Address � 4 1 nu City Lot Size/Acreage Owner's Name ARC=0 PfMIA06 1�0 Address 'P +�-11QX 501 I Phone Contractor We sleftorl Address & lT M License No.S57-vie __Phone TYPE OF WELL/PUMP: hFW WELL ❑ WELL REPLACEMENT I❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSSTEMRREPAIR ❑ OTHEP. ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK A4A SEWER LINES > 1WDISPOSAL FLD7 MMPROP. LINE ICS FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL_ PROBLEM AREA CONSTRUCTION SPECIFICATIONS !t El Industrial ❑ Open Bottom Manteca Dia. of Well Excavation I.Q PnCA Dia. of Well Casing C} Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing_PV C Specifications 1•I Public Cl Other Fl Delta Depth of Grout Seal �*��1lType of Grout _. I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by ]&�11,IIe-cS Repair Work Done ❑ Type of Pump H.P. State Work Done_. Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 faet.l (� Installation will serve: Residence— Commercial__,_ Other `J Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of FA Distance to nearest: Well Foundation Property Line RECIVLE LEACHING LINE Cl No. S Length of lines Total Length/size 0 9 1992 r FILTER BED ❑ Distance to nearest: Well Foundation Property Line SAN 16AQE1IN COUNTY � t SEEPAGE PITS 11 Depth Size Number_ FNVIRONMFNTAL HEALTH DivisioN SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 taws of California." Contractor's hiring or sub-contracting signature certifies the following: " rtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o1 Califw The applicant st c fo uir spsctiona. Complete drawing verse side. Signed Title: a61 a. Date: L FOR DEPARTMENT USE ONLY Application Accepted by Data �lrf 0�7i Area Pit or Grout Inspection by Date ��Final Inspection by Uzi Date ll Z Z Additional Comments: 3 / 1S � 5 R&112 � Applicant - Return all copies to: San Joaquin County Public Health Services ��Lirf /,;7U _9lp Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 1324INEV.rills) EH 14.10 r