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mai i- i APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 HERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in 'Triplicate) Application is hereby made to a" Joaquin County for a permit to construct and/or install the work herein described. This application is rade in cosrpliancei;with Ban 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 4Li Owner's Name A Phone lag- ontractordilis No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑: OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f INTENDED USE ` iTYPE OF WELL {PROBLEM AREA CONSTRUCTION SPECIFICATIONS .._- ❑ I ustrial ❑ ravOpen Bottom L7 Manteca Dia. of Well Excavation Dia. of Well Casing stic/Private '{❑ Gel.Pack [TTracy Type of Casing_ Specifications 1'1 Public 1_�f'1 Other - n Delta Depth of Grout Seal Type of Grout t I Irrigation l _IAppros. Depth I I E stein urface_Soul Irisialled by Repair Work pone U Type o!Pump' H.P. J�� T State Work Well Destruction La Well Diameter Sealing Material i Depth 4 '-i--Depth �L r Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION' I DESTRUCTION i I lNo septic system permitted if public sewer is available within 200 feet.) Instslbtion,.will serve:.fesidence_ Commercial Other . Number of living unity:,v Number of bedrooms ;r ` .- Character of soil to a depth of 3 feet: # �� f � rr table depth SEPTIC TANK. 1❑ Type/Mfg I Cspscity " 4 No. Compartments PKG. TREATMENT PLT1 D ' Method of Disposal rV Distance to nearest:_ Well .Foundation. Property Line I I LEACHING LINE ❑ No. & Length of iinfi Total length/size ` FILTER BED Cl Distanceto.nearest:' Well "�'�Foundation Property Lina SEEPAGE PITS II pth t+ Size Number 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 rubs and regulations of the San Joaquin County Home owner or licensed agent's iignature 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: "1 6e •fy that in the performance of the work for which this permit is issued, I shall employ persons subjecYto workman's compensa- tion laws of Californke." The applican call for ad in peetiens. Complete drawing on r ree side. :A Signed Titb: Dater �v FOR DEPARTMENT USE ONLY Application Accepted by Aw" Date '" � Area Ph or Grout Inspection by f Date Final Inspection by [j Data*41 Additional Comments: Applicant - Return all copies to: 'San Joaquin County Public Health Services Environmental Health PermitlBervices 445 N San Joaquin, P O Box 2005, Stkn, CA 95201 FEE AMOUNT DUE tA/MOUNT REMITTED It ICASH "RECEIVED BY DATE PERMIV ND. . EH 14-2 IREV. d�� r/O (,/5 [ y EH 4 •a6