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i� �I APPLICATION FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 ii (209) 468-3447 PERMIT' EXPIRES 1 YEAR VRQ9 PATE-- ISSU12 h (Complete in Triplicate) Appl tion is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This P 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. s Job Address3 02 1& City Lot Size/Acreage �L X Owner's Name Address �D Phone 2 7,? .I Contractor �i Address License No. Phone TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT E-1 DESTRUCTION A Out of Service well PUMP,INSTALLATION 13 SYSTEM REPAIR 0 OTHER p Monitoring well '`C] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS7SUMPS INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial © Opin Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack k�Tracy Type of Casing Specifications M Public I:1 Other ❑ Delia Depth of Grout Seal Type of Grout M Irrigation ..Approx, Depth 0 Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done C� Well Destruction well Diameter Sealing Material i Depth Cil Depth Il l�- Er', filler Material i Depth TYPE OF SEPTIC WORK: NEW,INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION GI (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— -Other r Number of living units: I Number of bedrooms Character of soil to a depth of 3 feel:. Water table depth i SEPTIC TANK- O `Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 ji Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ A 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, en rules and regulations of the Sen'Joaquin County Home owner or licensed agent's signature certifies the following: "l Certify that in the performance of the work for which this permit is issued, t 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." I The applies st call for all required inspections. Complete drawing on reverse side. Signed - Title: AEILDate: - 3 F USE ONLY lqk, Application Accepted by - Date r- Araa Pit or Grout Inspection by , Date Final Inspection by Date /6 Av Additional Comments. 'd Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE A OUNT REM#TIED ASH RECEIVED BY DATE PERMIT,NO. rNf O . EH 13-24(REV.I/A 51 r� Q'rte r o EM',41.14