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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 REMIT EXPIRES I YEAR PROM 12ATr&_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 aad Regulations of San Joaquin County Public Health Services. Job Address CityL;2; hrcp� Lot Size/Acreage Owner's Norm Bertha T- r '.. ice_ Address g�atfPhone 20 982-0466 A. Contractor_01.J m f3 ar : J Address License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION-- t of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSA PROP. LINE FOUNDATION AGRICULTURE WELL R WELL PITSlSUMPS INTENDED USE TYPE OF WELL PROBLEM CON ION SPECIFICATIONS f� Industrial ❑ Open Bottom ❑ Manteca f Well Excavation Dia. of Well Casing i LJ Domestic/Private ❑ Gravel Pack ❑ T Type of Specifications ❑ Public ill Other Delta Depth of Grout Se Type of Grout CI Irrigation _A Oepth ❑ Eastern Surface Soul InataNed by Repair Work Done 0 pe of Pump H,P. State Wo one_ Well Destruction. ❑ Well Diameter Sealing Material i Depth � Depth Filler Material i Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION INo septic system permitted if public sewer is r Installation will serve: Residence Commercial_ Other available within 200 feet.) Number of living units: Number of bedrooms Character of roil to a depth of 3 feet: Water table depth SEPTIC TANK. Type/Mfg j Capacity No. Compartments PKG. TREATMENT PLT.C7 Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. B Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth I Size Number SUMPS Ll 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 rules and regulations of the San Joaquin County laws, and Home owner or licensed agent'a signalure cenifies 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 shalt employ persons subject to workman's compensa- tion laws of California." The applicant must call for,all required ins ,coons. Complete drawing on reverse side. Signed ill _ Date: OR DEPARTMENT USE ONLY r r Application Accepted by Date Area Date Pit or Grout Inspection by DatFinal Inspection b Data�- Additional Comments: Applicant — Return all co les to: l ' P SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON. CA 98201 a FEE AMOUNT DUE AMOUNT REMITTED CK IiECEfVED BY INFO CASH DATE PEAMIT'NO. EMCs-?/IREV.iiMso :.�u ��