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f ' APPLICATION FOR PERMIT ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BQ% 2009,, STOCKTON, CA 95201 PEMIT ESP I RTsS 1 YEAR FROM DATE ISSREP (Complete in Triplicate) Application is hereby made to Ben 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 r 1�� t + City J� Lot Size/Acreage Owner's Name � y Address �~ 3 Phone _ 0 2J Contrattor � �m ryr 6��dress J 3 License No, Phone. - TYPE OF WELL/PUMP: NEV WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE W L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CO RUCTION SPECIFICATIONS L1 Industrial E ❑ Open Bottom El Manteca I of Well Excavation Dia. of Well Casing O fl Domestic/Private. ❑ Gravel Pack ❑ Tracy T pe of Casing_ - Specifications f I.1 Public CT Other f1 Delta epth of Grout Seal ° Type of Grout I i Irripalion _Approx. Depth I I Eas rn Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done T Well!Destruction. .. ,❑ 5 Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION P REPAIR/ADDITION I I DESTRUCTION I I INo septic stem p y permitted if public rawer is / available within 200 feet.) Installation will-serve: Residence Y Commercial ther r / t Number of living units: Number of bedrooms Character of soll.to a depth of 3 feet A Water table depth k SEPTIC TANK. t ❑ Type/Mfg Pq Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ / Method of Disposal" Distance to nearest: Well �oundsfion 1 Property Line Q i LEACHING LINE Cl No. Jl, Length of tines I Y Y 4,T To 1 length/size FILTER BED "" ❑ Distance to nearest. Well Rill 4 AAundation Property Line SEEPAGE PITS .11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS, ❑ 1 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 follo*ing: "I certify that in the performance of the work for which this permit is issued, I 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 mu call for all uired in etions. Complete drawing on reverse side. Signed Title -•�-�'l.[/[ _ Dote: J�. �=FDIEEPAROTMENT USE ONLY Application Accepted by 1 Date Area Pit or Grout inspection byData- Final Inspection by Dat 7 Additional Comments. Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin x 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DAT PERMIT'NO. f+ E 13-24 (J 1 Ek 11.7A tRtN. /rai !. 1 � Q� //� � ! rrv� 1V