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APPLICATION FOR PERMIT- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION 1601 P•0 BOX 2009ZELTONA,VSTOCKTON, CAE. , PHONE (209)469-3420 -3 20 95201 p ' PERMIT E%PIRES 1 YEAR FROM DATE ISSU$D (Complete 1n Triplicate) I ' Application is hereby mai San Joaquin County for a permit to construct and/or install the wdrk herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations o_ _ f,San,� B Joaquin County Public Health Services. + f r t '��', Lot Size/,Acreage Job Address �j1� tg�/ d Phone r ` //JJd M/yt Address t yr f �Owrar'sI me- ZEi Phone ._S 10 ' ¢ r r V ��11F'f r �---License Ns..a=u-"----- Contracl r o C "" Adtlress t `*'r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of novice well ❑ TYPE OF WELL¢PUMP:, r„ OTHER ❑ Monitoring Well fJ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ' DISPOSAL FLD. PROP. LINE h� DISTANCE TO NEAREST: SEPTIC TANK .�— SEWER LINES PITS/SUMPSI LL �— FOUNDATION AGRICULTURE WE ,— OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing (� ' ❑ Open Bottom D Manteca *Die. of Well Excavation i O fllndustrial Specifications t� Type of Casing— 0 Domestic/ ❑ Gravel Peck O Delta we Depth of Grout Seal Type of Grout I'I PuDlin (:1 Other Approx. Depth I I Eastern 't ✓Surface Seal Installed by ' I I Irrigation — - State Work Done _ Repair Work Done U Type of Pump H.P� Sealing Material & Depth 4 Wall Destruction ❑ Wall Diameter i Filler Material & Depth 5 Depth ' TYPE OF SEPTIC WORK. NEW INSTALLATION 11�• EPAIR Do ON DES7R;CTION availableJNo lc system per wthini 200 feet.) if public sewer is installation will serve: Residence Commercial Other Number of Awing unite: _-�a---� Number of be oms .. - - N/ater iatile depth ' Character of soil¢o a depth of 3 feet: ~ --a«-0 Type/Mfg Capacity No. Compartments `I SEPTIC TANK. C ❑ Type/Mfg � � Method of Disposal PKG. TREATMENT PLT. ❑ Property Line ' ,T Distance to nearest: e- Well - -' F I ndation f r No. & Length of lines 1 Total length/size Ql LEACH ;911 LINE ;911r rFou _ ndation Property Line FILTER BED Ll Distance to nearest,Jr Well. .-„ I I Depth Sized number SEEPAGE PITS r. _ __ properly Line SUMPS Distance[o Heaves[: ' Well u Foundation > p DISPOSAL PONDS ❑ I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ardinahces, state laws, and rules and regulations of the San Joaquin County I I shall not Horne owner or licensed agent's signature certifies the following::'.1 certify-that.in the performance of the work Dor which this permit is issued, employ any person m such mammal as to become subject to workmen's compensation laws of California,— Contractor's hiring or sulr;contrading signature 'p eertlliea the follow °'t certify that in 3he'performance'oYlhe work for which this permit is issued, I shall employ persons subject to workman's eompensa- ¢ion laws of California." �ti. �r,, l ^ The applica t"call V f r® tree Inspec[ion'a. 00mplet'e drawing on reverse sid�.,{� i\\ .�J I Date: Signed Title: ; R PgRTMENT USE ONLY ` Date 1 7i Area ^ ' Appllcalion Accepted by Pit or Grout Inspection by Date Final Inspection by w :t Date s Additional Commea: m ? r �i Applicant - Return all copies to: San Joaquin County Public Health ' n Services, Environmental Health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 . r FEEAMOUNT REMITTED CK ECEIVED BY j ATE PERMIT'n'0. ' 0 INFO AMOUNT OUE e EM 1734(FEY.11.5) EH i43e