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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 t ii P 0 BOX 2009, STOCKTON, CA 95201 ARMIT EXPIRES 1. YEAR FROND T i (Complete in Triplicate) _ t Application is hereby made to San Joaquin County for a permit to construct and/or install the work berein described. This application Is made in Compliance with San J in County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. p / �ob Address c i City Lot Size/Acreage +(� d `tel] Phone T KO Wflef s Name eAOdfe54 v r 11 ' L ntraclor �" Address License Na. ` Phone TYPE`OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17.1 - DESTRUCTION c) out of Service well D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ y'OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION C AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r 0 Industrial ❑ Open Bottom. 0 Manteca Dia. of Well Excavation Dia. of Well Casing I Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications <il Public fl Other ': Cl Delta - Depth of Grout Seal Type,of Grout 4 _,! I Irrigation Approx. Depth l I Eastern Surface Sedi installed by a Repair Work Done U . Type of Pump H.P. Stats Work Done f Well Destruction , O Well Diameter Sealing Materiel F Depth _ Depth Filler Naterial i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION (No septic system permitted if public sewer iz .i f vailable within 200 feet.) Installation will serve: Residence— Commercial. `_ other I Number of living units: Numberofbedrooms Character of sag to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg 4 Capacity No. Compartments PKC. TREATMENT PLT. 0 _ P Method of Disposal ;.Dlatance to nearest: Well Foundation Property Line LEACHING LINE Cl No. S Lengt�of lines Total length/size FILTER BED 1:1Distance to.nearest: Well 4 i Foundation Property Dine - SEEPAGE PITS 11 Depth f Size ` Number SUMPS Ll ' Distance to nearest: Well } Foundation Property Line 'DISPOSAL PONDS 0 ! I hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin county ordinances, state laws, and } _ rules and regulations of the San Joaquin County �- ` r Home owner or licensed agent's signature certifies the following: "I certify that iwthe performance of the work for which this permit is issued, I shall not 4 :a employ any person in such manner as to become subject to workman's compensaiion 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 lams of California." ' f) The applicant must call•for all r utred inspections. Complete drawing on r side. - Title; pate: - �� i •�,:.- _ FOR IDEPARTMENT.USE_ONLY.- Application Aeeepted by cvc,d&�L Date �- Area �- Pit or Grout Inspection by Data Final Inspectio r�'`c-�' '7Date3 Additional Comments: NAt Applicant - Return all copies to: San Joaquin County�Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, 8tkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO /�r1n n_ �7