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!b' APPLICATION FOR PERMIT SANT JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT MIRES 1_1E FROM D T I OM iii (Complete in Triplicate) Application is hereby made to sea Joaquin County for a permit to construct and/or install the work herein described. This application is made in co�liance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.Ii /r City " `Jb'A Lot size/Acreage M�+Pf1 Joh Address , Address �WO Uk a tk�� o-• " " Phone d Owner's Name i� � wb rv� �f; �i� Address ��` ��° 1 i`3 `license No. K� 63 Phon Contractor DESTRUCTION ❑ Out of Service Well C1 TYPE OF WELLIPUMP: ! NEW WELL ❑ WELL REPLACEMENT L1 c f 14onitori well ❑ PUMP INSTALLATtQ�N ❑ SYSTEM REPAIR ❑�-a��1 �f:`n�� OTHER � +' SEWER LINES ZCI� DISPOSAL FLD. AI PROP• LINE ��/ DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS ='! a FOUNDATION + AGRICULTURE WI L OTHER WELL I+ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 1 C7 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Type of Casing_ Specifications } I'1 Domestic/Private ❑ Gravel Pack L7 Tracy Depth of Grout Seal f yps of Grout i I'I Public .1 Other t1 Delta I I Irrigation —.Approx. Depth I I Eastern Surface 5enl Installed by H P State Work Done.._. Repair Work Done U Type of Pump Sealing Material i Depth Well Destruction 0 Well Diameter Tiller MaterialMaterialIII Depth Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I l avaiiabietwi hin 200 feetsystemtjed iT public sewer is Installation will serve; Residence— Commercial_ Other ` Number of living units: �1. Number of bedrooms 1 Water table depth Character of soil to a dapthi of 3 lest: No. Compartments MTg SEPTIC TANK. ❑ J�TypelCapacity Method of Disposal PKG. TREATMENT PLT.❑ ':.!Distance to nearest: Weil Foundation Property Line i LEACHING LINE LT i No. 6 Length of lines Total lengthlsil kFILTER BED 0 Distance to nearest: Well Foundation Property Line Ii 1� SEEPAGE PITS 11 j DSize Number SUMPS LI :1 Distance to near) Weil 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 d rules and regulations of the San Joaquin County i Horne owner or licansad agent's signature canities the following; "I certify that in the performance of the work for which this permit is issued, f shall not t ampby any person in such rrisnnar as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following:"I cavi.that in the performance of the work for which this permit is issued,i shall smploy persona subject to workman's compensa tion laws of California." I I The applicant nn tali all required inspections. Complete drawing on reverse$i d 7` 1f Title: i Date: Signed FOR DEPARTMENT USE ONLY ti` ' Application Accepted by DatB� � Area w . Dau � Pit or Grout Inspection by Date Final Inspection by*"`t r Additional Comments: '3 S F std la i Applicant - Return ail copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 IF FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED t!Y DATE PEftMI t Np. INFO /p CASHp f , EH 13-Z/tREv.+inat �� ,. fJ�Q� �(�� EH U-76 IM