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" APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 J A'N 0 3 -09 (209) 468-3447 eti IRONMENTAL HEALTH YEAR tPERMIT/SERVICES (Complete in Triplicate) . y Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This application is made in cmwliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules aad Regulations of San Joaquin County Public Health Services. Job Address �'r1��—J� - _.— City Lot Size/Acreage !� � (PP f V Owner's Name '�" , '� Address hone e No. Phone9_& v /� C r ctv �JZ� dress Licens TYPE OF WELL/PUMP: N WELL fa WELL REPLACE EN7 ❑ DESTRUCTION ❑ Out of Service Well Ll PUMP INSTALLAT101� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE T_O,NEA_REST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ _ y 't INTEND USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial '" ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing gB mestic/.Private_` ,, ❑ Gravel Pack ❑ Tracy Type of Casing Specifications /❑ Public I"1 Other ❑ Delta Depth of Grout Seal Type of Grout �'� —.Approx. Depth astern f ce Seal Installed b G trliUetii]n., I Repair WornDone Type of Pum H.P. to or o s Well.Destruction O `*Weil Diameter Sealing Material i Depth Depth -- -Jiller Material i Depth i TYPE OF-SEPTIC WORK:- -NEWINSTAL'LATION 0- REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted if public sewer is available within 200 fest.] Installation will serve: Residence— Commercial— Other W Number of living units; Number of bedrooms Character of soil to a depth of 3 feet: Water table„depth j SEPTIC TANK. ❑ Type/Mfg Capacity *i No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line [] LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ . ........... I hereby akify that I`heve 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 Sen 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 California." The applies `at ca 1,or E r quire inspections, Complete drawing on rover a side, TITU sl al Sign Title: e: FOR DEPARTMENT USE ONLY f n Application Accepted by Date 7 4/ Area Pit or Grout Inspection by Date Final Inspection by v Date Additional Comments. — Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 945 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. iNFO CASH R r r , EN 13.24IREV.1�45i I�� '�'�♦�r`7 1 ell--DOG • EN 114-MI 1