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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-344? PERMIT EXPIRES 1 YEAR FROM DATE IaMM (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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �j� -- "� �� City Lot Size/Acreage Owner's Name �n=- Address f n' J110 >/rW Phone 1 ContracP4 / Addres�L�p wiLicense N^� P h o TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION O 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 * Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing 0) U Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications M Public CI Other ❑ Delta Depth of Grout Seal Type of Grout CI Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by 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 0 REPAIR/ADDITION DESTRUCTION (No septic system permitted if public sewer is --:� available within 200 feet.) / Installation will serve: Residence X Commercial� �/`'``��-. Other - - Number of living units: _L_ Number of bedrooms T ' Character of soil to a depth of 3 feet: Water table depth 7% SEPTIC TANK Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT, O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines Total length/size FILTER BED C) Distance to nearest: Well Foundation -_-�7X7, Property Line ^ SEEPAGE PITS I I Depth Size Number SUMPS V--0istance to nearest: Well r[[T Foundation Property Line DISPOSAL PONDS ❑ 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 persons subject to workman's compensa- tion laws of California." The applicant must call for all require , tions. Com to drawing on reverse side. a Signed z Title: \_'C -' I- Date: ' �1RTMENT USE ONLY Application Accepted by L o� \�s k Date Area _ Pit or Grout Inspection b/y, Date Final Inspection b _ - ' Date Additional Commme e✓� f / �(�. Applf-ctCtint=�i`(et�i �` es�?. ' O Jj iii'✓l'�f � �RVE3 " /'�j d�f�EQ/, f�f//�',� 00- C OA ICOUNTY PUBLI HS TH E ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUN/T 'DU(E AMOUNT REMITTED CASH RECEIVED BY DCK If ATE PERM17'NO. . EH 13-24UEV.rin5r 1 U i Vd Q17r") �� EH i�•� l T( l