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APPLICATION FOR PERMIT o SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468--3447:3 4)0 PEMIT gMigR5 I REAR rROM DATE L SUS (Complete in Triplicate) Application is hereby siade 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 Healt�Fhl Services. C /'Job Address 1 .(7�0 II° �t C �� CitY `-� � Lot size/Acreage t cL�4-t nn L- -7:7 �Owner's Name E ` I ddressf` Phone Contractor L - I Address License No. Phone TYPE OF WELL/PUMP: !� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUM INSTALLATION ❑ SYSTEM REPAIR 0 OT p Monitoring Well DISTANCE TO NEAREST: SEPTIC SEWER LINES DISPOSAL FLD PROP. LINE FOUNDATION AGRICULTURE WELL OTHER L PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEA CONSTRUCTION IFICATIONS f_'} Industrial ❑ Opin Bottom 0 Manteca of xcavation Dia. of Well Casing i Specifications U Domestic/Private ❑ Gravel Pack ❑ Tracy e o g M Public Cl Other ❑ Delta Depth of Grout Type of Grout l lrripation _ . Approx. Depth astern 5urfaea Seal Installed by Repair Work Done U Type of Pum H.P. State Oone ._ Well Destruction ❑ Well Diameter Selsling Material i Depth Dept#il Filler Material i Depth TYPE OF SEPTIC WORK: NEWINSTALLATION L7 REPAMIADDITION L-I DESTRUCTION iNo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence— Commercial Other Number of living units: I Number of bedrooms Character of soil to a depth of 3 feel. Water table depth SEPTIC TANK © Type/Mfg C city No. Compartments PKG. TREATMENT PLT.❑ f '' � od of Disposal ; Oilstance to nearest: Well pu Ili r i e 11 LEACHING LINE 0 No. & Length of lines _ r■p FILTER BED Cl Distance to nearest: Well- ��-- 1'F y rffrQ�VtA Elf a, ins SEEPAGE PITS 11 Depth Sire E? SUMPS LI Distance 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 rules 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 taws of Calif rnis." 1 - I The applicant st 11 for I required inspections. Complete drawing on reverse side. 1 is y\Signsd Title: Date II FO PART USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2000, STOCKTON, CA 05201 FEE AMOUNT DUE AMOUNT REMITTED CK IRECEIVED BY DATE PERMIT'NO. INFO CASH . EM 17.24 1REV.r/Pl41 i•Qty 03 L4 L+ ;3 � '�.•! l l �•+�r/ EH 14.28