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Y APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 ' PERMIT EXPIRES I XEAR FROM DATE ISSJIM (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in cmwliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquia County Public Health Services. Job Address -113f r '3j City Lot Size/Acreage 7 f t 40 Address Phone- Owner's Name r Contrac�WLL/ Address a License No. Phone ell 0 Typp OMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of fonitoring SNfell D PUMP INSTALLATION O SYSTEM REPAIR O OTHER O DI NCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTEND USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Casing Cl Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing_ S -+cations .- - 1 I"I Public Other Cl Delta Depth of Grout Seal ype of Grout I I Irrigation �. pprox. Depth I I-'Eiist6in""" —Surface-Seullnstalled-bv — ' Repair Work Done L] Type of mpa H.P. State Wor one Sealing Material i Depth Well Destruction D Well Dismal I Depth tiller Material h Depth I rmi TYPE OF SEPTIC WORK: NEW INSTALLATI l I REPAIR/ADDITION I I DESTRUC N available ble within 20ic system feet, ed it public sewer is Installation will serve: Residence— Commercial Other 4 Number of Irving units: Number of bedrooms Chatactn of soil to a depth of 3 feet: Water Lobb depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: ell Foun ion Property Line LEACHING LINE ❑ No. & Lengt lines Total Length/size FILTER BED ❑ Distance nearest: Well Foundation Properly Line I SEEPAGE PITS I I pth Size Number SUMPS Distance to nearest: Well Foundation Property, .n DISPOSAL PONDS ❑ I hereby certify 1 i have prepared this application and that the work will be done in accordance with San Joaquin coun ordinances, state laws, and rules and r tions of the San Joaquin County I Home o r or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this per is issued, I shall not ! s any person in such manner as to become subject tocworkman's compensation laws of California."Contractor's hiring or sub c ratting signature rtifies the following:"I comfy that in the performance of the work for which this permit is issued,I shall employ persons subject to work a compensa tion laws of California." The applies if requs coons. Com d Ing on rave se side. Signed Title: Date: FOR DEPARTMENT USE ONLY `4 Application Accepted by �' 7�O.a ""- Date �+ S Area o'), 2 Pit or Grout Inspection by Date Final Inspection by Data 3, Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CA R CEIVE0 BY DATE PERM17'N0. INFO / f . EH1344(REV.4/x$I � � t l � �L� CH ICU 4