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i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE..ISSUIED (Complete in Triplicate) Application is hereby made to Sam 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 Do. 549 and 1862 and the Rules and Regulations of San Joequin.County Public Health Services. / City Lot Size/Acreage Job Address J�fd �3�l�csf - _ I r- - -rJLI� " Address Ab Phone' Owner's Name' ' Contractor Address ! f License No. Phone / TYPE OF WELL/PUMP: NE WELL ❑t; WELL REPLACEMENT n DESTRUCTION ❑ out of Service well Ll OTHER Monitoring We PUMP INSTALLATION ❑ ` SYSTEM REPAIR X e.PW44 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Type of Casing Specifications fiDomeasic/Private C1 Gravel Pack ❑ Tracy i"1 Public f-Z Other fl Delta Depth of Grout Seal Type of Grout 1 _Approx. Depth I I Eastern Surface Seal Installed byI I Irrigation r • r H.P. State Work Done Repair Work Done ❑ Type-of-Pump �,�a4� Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK:- NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION t I INo septic system permitted if public sewer is available within 200 feet.) V) Installation will.Terve: Residences Commercial— Other Number of living units: Number of bedrooms Charactsf of soli to a depth of 3 feet: Water table depth SEPTIC TANK © Type/Mfg Capacity No. Compartments ---�. PKG. TREATMENT PLT.❑ Method of Disposal G Distance to nearest:~-- Well -- Foundation Property Line r `j LEACHING LINE 0 No. b Length of lines Total length/size FILTER BED 11 Distance to nearest: Weil Foundation Property Lina SEEPAGE PITS 11 Depth,, Size Number SUMPS LI Distince-to nearest: Well' -- Foundation Property Line DISPOSAL PONDS ❑ �" I 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 rubs 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 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 must cell for all required inspections. Complete drawing on reverse side. Signed 14 Title: Date: hZ F w i FOR DEPARTMENT USE ONLY l Applice1tlon Accepted by �f � Date Area'- Pit or Grout Inspection by Date �I Final Inspection by - Data —L6[+t { Additional Comments: lj, f t Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services `�(J 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. INFO [� CASH ' . EH 0.24INEV.I/P15) (�[S�� l J� Or JD a0 (._7�//4 EH 14.25