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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES a � ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 tJQ LVAD P 0 BOX 2009,. STOCKTON, CA .95201 N� ERM T EXPIRES I YEAR FROM D TE—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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. J(Job Address 5rJ y.c + City S Lot Size/Acreage Owner's Name 6 Address Phone Contractor A 0� 'Alfdress L'icen'se No. Phoned 1 TYPE OF WE / UMP: �NEELL ❑ WELL REPLACEMENT .. DESTRUCTION ❑ Out of Service Well ❑ PUMP.IN.STALLATION ❑ SYSTEM REPAI OTHER ❑.. Monitoring Well ❑ DISTANCE TO NEAREST: SEPT, I TANK SEWER INES " DISPOSAL FLD._ PROP. LINE FOUNDATION AGRiCUL URE WEL __ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS ._ 0 Industrial ❑ Open Bottom ❑ Manteca is, Well Excavation Dia. of Well Casing (\ Cl Domestic/Private ❑ Gravel Pack L7 Tracy Type of ing_ Specifications i'1 Public Cl Other Fl Delta Depth of Grou al Type of Grout I I Irrigation Approx, Depth I I Ea rn Surface Seal Installed by Repair Work Dona v Type a} Pump N.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Nateriwl A Depth i Depth Filler Naterial i Depth ! TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION-( I DESTRUCTION tNo Septic system permitted if public sewer is 'available within 200 feet.) Installation MI serve: Residence— Commercial Other Number of living units: Number of bedrooms Character of 804 to adepth of 3 fest: Water table depth SEPTIC TANK. ❑ Type/Mfg Cijiaci y .. ` No. Compartments PKG. TREATMENT PLT, Q Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.& Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Propeny Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ f - 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 rules and regulations of the San Joaquin County I Home owner or licensed agent's'signature oenifies 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 subcontracting signature certifies the followi : "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- ton laws of Califor The applican call for all wired inspections. Co ate drawing on reverse side. XSigned Title: I i FOR DEPARTMENT USE ONLY i Appkication Accepted by �b .�nA _._ _ _. _ Date Area e•:• - � Pit or Grout Inspection by Data Final Inspection by Date , Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services r 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ECEIVED BY TE PERMIT'NO, INFO AS �7 r . EM1321 IIIEV,tiAst EH i4-2a /