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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT E%PIRES 1 YEAR PROM DATE ISSUED (Complete in Triplicate) Application is hereby ttade,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. �J ��^/ Job Address --�� 191T,_ City :Y Lot Size/Acreage Owner's Nsme��-may/�� S/r r�y Address F�:n 110 Phone Contractt/4 f Addresx�ll6 /LL iLicense N^� «�Pho TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION O Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ci industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing (J) U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications * Public i'1 Other ❑ Delta Depth of Grout Seal Type of Grout C❑ Irrigation —Approx. Depth D Eastern Surfice Seal Installed by Repair Work Dons ❑ Type of Pump H,P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION INo septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence x Commercial,9- Other � 1 - Number of living units: i 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. O Method of Disposal O Distance to nearest: Well Foundation Property Line LEACHING LINE No. b Length of lines — � — Total length/size FILTER BED C) Distance to nearest: Well— Foundation �f Property Line SEEPAGE PITS I I Depth Size .��Number SUMPS Y-Distance to nearest: Well 2 Foundation _G� 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 applicant must call for all requir tions. Com to drawing on reverse side. n Signed '—Title: \ Date: �- 14 : �RT�MENT USE ONLY Application Accepted byCA._ a ,Iqs Date Area 12) Pit or Grout Inspection by a Date Final Inspection b ` Date Additional Comr�rw/n s1JE r �G ,�► f r Ayplfictht - ettUrn '?� OAQUIN COUNTY�PUBLI� H T�liR9 E3 �� f�f'f�'/. /f//f7� C ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH Kif RECEIVED BY DATE �n{PERMIT NOn. . EH 13-24(REV.iie6) r l .00 EH's•= -)I_14-3111I 11 Q�'lL/ l V