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APPLICATION FOR PERMIT 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 1 YEAR FROM 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 in 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 G w�"-- �� City Lot Size/Acreage v 6 i Owner's Name Address / �� L- PhoneMJiii �/y 404Contractor dress __ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ EL REPLACEMENT n DESTRUCTION O Out of service Nell ELL ❑ PUMP INSTALLATION ❑ YSTEM R AIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTU OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM ARE ONSTRUCTION SPECIFICATIONS Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private O Gravel Pack ❑ Trac Type of Casing__ Specifications \ I'1 Public Cl Other fl D to Depth of Grout Sea( Type of Grout I I Irrigation —Approx. Depth 11 stern Surface Seal Installed by �h\ Repair Work Done U Type of Pump H.P- State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial �ther Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 41 Water table depth SEPTIC TANK O Type/Mfg ` p Capacity U No. Compartments PKG. TREATMENT PLT. O Method of Di al Distance to nearest: Well rlr� Foundation Property Line Z 2 `r LEACHING LINE Cl No. b Length of lines 2- U U -yC d TF' I len gth/size ' FILTER BED O Distance to nearest: Well / f Foundation Qo Property Line SEEPAGE PITS 11 Depth1.Depthumber SUMPS LI Distance to nearest: It 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 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 applicantRust call for required ins coons. Complete drawing on reverse side. /� Signed Title: Date: l)^ V FO DEPARTMENT USE ONLY ��'',, �� Date © � Area Application Accepted by �N�C'`�� Y`� �' - 7 Pit or Grout Inspection by Oats Final Inspection by Date / Additional Comments: Applicant - Return all copies '�to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK R CEIVED BY DATE PERMIT NO. INFO /�/J//7 eH 13-N(REV.I/F1 Sr L t L� t// OD �(�� / f / FH tt-2a