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APPLICATION FOR PERMIT 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 lien Joaquin County for a permit to construct and/or install the work herein described. This application is made in Compliance With Sen Joaquin County Ordinance No.. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. YJ � 1 ' & .ob Address i - City Lot Size/Acreage tOwr's Nams rasa iJ�4°L`I R k Phone 9) ,ctorAddress -71 `` n� o. Phone TYPE OF WELL/PUMP: NEW,WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR, OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONII AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industriai ❑ Open Bottom-_ ❑ Manteca. Dia. of_Well.Excavation Die. of Well Casing 1.1 Domestic/Private El Gravel Pia 4 " ❑ Tricy Type of Casing_, Specifications I"I Public 1:1 Other i fl Delta Depth of Grout Seal Type of Grout I I irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump I H.P. Stats Work Done Well Destruction ❑ Well Diameter Sealing Material A Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION I I DESTRUCTION I I lNo septic system permitted it public sewer is I available within 2W feetJ Installation will serve: Residence_ r 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 l Capacity No. Compartments PKG. TREATMENT PLT.Cl Method of Disposal, Distance to nearest: Well Foundation Property Line q LEACHING LINE Cl No. fi Length�of tines Total length/size i FILTER B1EDCl Distance to _nearest: Well Foundation Property Line G' 1 SEEPAGE PITS 11 Depth Size Number {� SUMPS Ll Distance to nearest: Well Foundation Property Line �✓ DISPOSAL PONDS ❑ I 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: '9 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." Contractors 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 Iowa of California." Tpe applicant must call for all required inspections. Complete drawing on reverse side. Signed K. : ... ... Title:S��EZ- _ Date: _�_ � rt - OR DEPARTMENT USE ONLY i Application Accepted by (�4 �beee,�-- _ Date A d2-- Pit or Grout Inspection by Date Final Inspection by Dats�/O Additional Comments: Applicant •- Return all copiee;to: San Joaquin County Public,Health Services Environmental Health`Permit/Services t 445 N San Joaquin, Pyo Box 2009, Stkn, CA 95201 INFE AMOUNT DUE AMOUNT REMITTED CASFt1 RECEIVED BY DATE PERMIT"NO. , EH 13.21(REV.tiR.El T� Li_/ 'ig L - •d_0 EH 11.1E