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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PE_MIT_E_XPIRES 1 .Y R VROPd DATE 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 and Regulations of San Joaquin County Public Health Services. /�fJ/))Q� Job Address �(/�! �v �� - Cityi`"`_1 — Lot Size/Acreage Owner's Name ��a�c Address 7�r �r1/ /�°S Phone Contractor GSS /2)/71 dr�ss �5 " L/lUColi", /icense No. � G'�� Phone 5 � TYPE OF WELL/PUMP: NEW WELCK WELL REPLACEMENT O DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR O OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS In ustrial ,Open Bottom O Manteca Dia. of Well Excavation`� �/��-- Dia. of Well Casing mestic/Private Cl Gravel Pack O Tracy Type of Casing___S_t�r Specifications Public CI Other ❑ Delta Depth of Grout Seal �t�?__ Type of Grout Cl IrnUation �Q Approx. Depth ❑ Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. :2 State Work Done Well Destruction O Well Diameter Sealing Material i Depth 1 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION L REPAIR/ADDITION Ll DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.) lllJJl Installation will serve: Residence _ Commercial _ Other O Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line _ LEACHING LINE L1 No. & Length of lines _ Total length/size FILTER BED C1 Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS 11 Depth Size — Number SUMPS LI Distance to nearest: Well Foundation_ Property Line DISPOSAL PONDS O 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 laws of California." The applicant must call for all rl d inspections. Complete drawing on reverse side. Signed X_L�s� l Title: / �-+--,�--� Date: 4�2 _ F �YMENT�USEONLY Application Accepted by Date 2"�" Area 1 2— Pit orro Inspection by _¢f / VlFinal 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 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INF CASH EH 13-:1(REV.I i n 5rEH 4 .. 13 j .��i 1 I�iif✓ � � I Ct' +CJ.tip Z� �� Cl I -032.12 P