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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES w ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 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 PublicHealthServices. ___Z1 Job Address .T -� (� ��• ,� Ly Cicv 1A �Lot Size/Acreage Owner's Name Address ��✓ �-�/ A�i� /�/ Phone �7Z/ Contract Address ar&_W�. �� License Nom—,�` Phone TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications M Public I'1 Other ❑ Delta Depth of Grout Seal Type of Grout G Irrigation Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth CIO Depth Filler Material i Depth r— TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION7,,DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial` Other Number of living units: 4— Number o�drooms � Character of&oil to a depth of 3 feet: 242 A77 �_ Water table depth SEPTIC TANK ) Ll Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well undation �_ Property Line ' SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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, 1 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 person'subject to workman's compensa- tion laws of California," The applicant mu cal equir i ctions. Z`omplst drawing o rse side. Signed Title: I Date:(.JL - OR DEPA MENT USE ONLY Application Accepted by Date ea Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE K S ZE1 AMOUNT DUE AMO/UNT REMITTED CASH RECEIVED BY DATE G PERMIT'N0. . EH 1,.�111EV. i n 51 G / ' a 1( , O-D (ptZ ee �^ ^ G ' 13 a d J