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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 # PFaMIT EXPIRESI MAR rROMd DATE ISSUED r (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 Stade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services, /Jab Address o �� `" City �� of Size/Acreage �G l 0 er's Name, 4 G rl C1T�',T l�� Address � � ' Phone ., Gbtrtf ctdiw -Z. _.�Address. TYPE OF WELL/ P. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Ou of Service Well L❑ STALLATION ❑ SYSTEM REPAIR L7 07 Monitoring Well (7 H � , DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL F� PROR._LINE ` FOUNDATION RICULTURE WELL 0 f WELL PITS/SUMPS _ I INTENDED USE TYPE OF WELL PROBLEM AREA ti NSTRU SPECIFIC ,TIONS - r 0 industrial ❑ Open Bottom ❑ Manteca Di I Fxcaveiion '. " Dia. of Well Casing k' U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �l Public (_.1 ether a Depth of Grout Sea! I Type of Grout CJ Irrigation ,w.Appror. D ❑ Eastern Surface Seal Installed by _j Repair Work Done U Type mp H.P. State Work Don r Wall Destruction ❑ ell Diameter Sealing Material i Depth f Depth Filler Material i Depth 5-< TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION CI DESTRUCTION CI INo septics stem h0 ffeet.)ed if pus blic sewer available witin,20 + Installation will serve: Residence_.. Commercia Other �= „# 1 Number of living units: ,,,Z- Number of bedrooms Character of wit to a depth/0 3 fool- —Water_ Water ti51e depth SEPTIC TANK /Mf 11 2y • 7 —C= ` YPa g Capacity _ - NoCompertmanta � PKG. TREATMENT PLT, Cl Method+of Dispose! t '� Distance to nearest: Well Foundation. Property Linot LEACHING LINE No. & Length of lines Total Ienalh/size FILTER BED IV Distance to nearest: Well a <=--=-! Foundation '-NPropeny Line SEEPAGE PITS $4" Depth / Size l Numb A�- 4.ti SUMPS L1 Distance to nearest: Welt Foundation Property Line ' DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be da in' accordance'wiih 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 perfo manta of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmen'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 calf for allr fired inapactio omplete drawing on reverse side, F �+ Signed Titla_ ate: A F DEPARTMENT USE ONLY q Application Accepted by Date�J I rsa Pit or Grout Inspection by Date Final Inspection Dated Additional Comments. Applicant - Return all copies to: SAN JOAQUIN COUNTY PU13LIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 INFO EEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EHA-29