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APPLICATION FOR PERMIT q y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I LEAR FROM DATE ISSRED (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. Job Address City Lot Size/Acreage rr � ~� Phone Owner's Name Address r Contralto 4d/dress e No. Phone I `' TYPE Of W L PUMA: NEW WkL O WELL REPLACEMENT ❑ I DESTRUCTION 0 Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 CI Industrial 0 Open Bottom 0 MantecaDia. of Well Excavation Dia. of Well Casing Cl Domestic/Private Ci Gravel Pack 0 Tracy Type of Casing_ Specifications [1 Public El Other, n Delta Depth of Grout Seal Type of Grout I I Irrigation —,Approx. Depth I I Eastein Surface Sedl Installed by Repair Work Done L] Type of Pump r H.P. State Work Done Wall Destruction 0 Well Diameter Sealing Naterisi A Rept r Depth i Piller Material ti pth r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Numl5ar of bedrooms Character of soil to a depth of 3 feet: Water table}depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 _ 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 Property Line 14 SEEPAGE PITS pth , Siie Number SUMPS -1 Distance to nearest: Well _ Foundation T!Q Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 Horne owner or licensed agent's signature certifies theJollowing: "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 cartify that in t mance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I The applicant must call all in ct' ns. Comp) to awing an =rse Signed Title: Date: FOR DEPARTMENT USE ONLY J� tion Accepted by Pats Area Pk or out Irlspactbn by Date Final Ina c'on y Date l v r f Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services �iZGiC�/ Environmental Health Permit/Services ))� 445 N San Joaquin, P O Box 2009, Stka, CA 95201 17 - FEE AMOUNT DUE AMOUNT MATTEDt CElvte ey DAT PERMIT NO• INFOC 6 H [/may . EN 13-24(REV.r/till EN 14.26