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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES —ENVIMEN RONTAL 'HEALTH DIVISION- r445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YZAR EROM 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 ccaplience with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1 rt Job Address City I Lot Size/Acreage 4 Phone Owner's Name ` s - Address �ifsi4 ® Contractor jttAl 191-1-111* Address 1 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well n SYSTEM REPAIR OTHER ❑ Monitoring Well PUMP INSTALLATION ❑ ,.�" r DISTANCE TO NEAREST: SEPTIC"ANK �� SEWER LINES'-� fl15PpSAL FLS PROP. LINE .. FOUNDATION -AGRICULTURE WELL 2? OTHER WELL PITS7SUMPS I' INTENDED] USE TYPE OF WELL ti" PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial r ❑ Open bottom ❑ Manteca iiia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Graval.Pack ❑ Tracy Type of Casing-- Specifications f a'] Public } [I Other ;;� I-1 Delta Depth of Grout Seal Type of Grout I I Irrigation s �.Approx. Depth I I Eastern Surface Seal Installed by Repair Work pone 0 Typs of Pump T+4— H.P. — `�- —_ State Work Dons • Well Destruction .❑ Well Diameter '# _ Sealing Material ii Depth f *' Tiller Material i Depth Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I l DESTRUCTION 1 1 INailab septic system shin ZOO Bitted if public sewer is Installation will serve; Residence t �+Commertisl^ Other Number of living units: Number of bedroom's Charactai of soli to a depth of 3 feet.-€ Water table depth SEPTIC TANK ❑ Type/Mf q' x' ' ' Capacity No. Compartments t> " Method of Disposal ' PKG. TREATMENT PLT. ❑ f[{[{ ?r`' Distance to n"rest: ,,,,,.,.Well Foundation Property Line LEACHING LINE d` L No. & Length-of-linea ' Total length/size FILTER BED O Distance to riearast: Well ` Foundation Property Line {" "f"r I t SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well .Foundation Property Line i DISPOSAL PONDS ❑ �� I hereby certify that I have prepared ih1i application and that the work will be done in accordance with San Joaquin county ordinances, sista laws, end r 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, I shalt 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,1 shall employ persons subject to workman's compensa- tion laws of Catifofnia." The applicant mutat all for required 'ns tions. Complete drawing on rev side.- , - r2 Signed Title: Date: r FOR DEPARTMENT USE ONLY Date 7i Area Application`Accepted by T- � t Ph or Grout Inspection by Date Final Inspection by Date i Additional Corn"Writs: ' s i Applicant - Return all copies to: San Joaquin County Public Health Services 1 Rbvironmental Health Permit/Services i YI 445 N San Joaquin, P 0 Box 2005, Stkn, CA 95201 i Y FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. INFO re, C EN,174/(REV.riwa) `M 1�•7a