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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby =Ae to San Joaquin County for a permit to construct and/or 1nsta].2 the work herein described. This application is made in coopliance vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1 Job Address ` z City Lot Size/Acreage 11 wrler's Nems r / Address Phone `IJ 69 r for Fess + ansa h - Phone TYPE OF WELL/PfiIMP: NEW L ❑ WELL REPLACEME T �) DESTRUCTION Cl Out of Service Well 0 i PUMP INSTALLATION O SYSTEM REPAI QTHER ❑ Monitoring Well L] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L3 I ustrial Cl Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing l�stic/Private 1 D Gravel Pack 0 Tracy Type of Casing, Specifications F. I'I Public n Other f7 Delta Depth of Grout Seal Type of Grout i Irrigation ! Approx, ltt� Y r Eestorn Su a Sanl Iruuusd by lz Repair Work Done U Type of Pump p� H.P. _ State Work Done t�r Wes Destruction f ❑ Wefl Diameter t3ealing Material i Depth , L i Depth Filler Material i Depth _ ✓ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted-d-public sewef is { .available within 200 feet.) n Installation VA `erve: Residence_ Commercial_ Other t Number of Living units: Number of bedrooms Cr s Character of will,to a depth of 3 fleet: — Water table depth SEPTIC TANK 1 ❑ Type/Mfg Capacity No. Companments -� PKG. TREATMENT PLT. 0 Method.of Disposal Distance to nearest: Well Foundation Property Brief , LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED 1 O Distance to nearest: Weil Foundation r-----Property Lira SEEPAGE PITS j 11 Depth Sire Number SUMPS LI Distance to neaten: Well Foundation' Property Lina DISPOSAL PONDS.' ❑ f i I hereby certify that{!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 agem's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell not employ any person in such manner as to bkmrw subject to workman's.compensation.laws-of-Colifornia.'"-Contractor's hiring-or-sub-contracting signature tionila the wing: I candy that in the Wormance of rhe work for which this permit is issued, I shall employ persons subject to workman's componsa- tion larva C 'fmia." The ar �77Z caU uir inspsct)ons. Complete drawing o r er Signed ) Titl 4 Dote: FOR DEPARTMENT USE ONLY J AppHcation Accepts by ,J A T Date 2 Area Q t Pit or Grout Inspect;n by Date Final Inspection by Date 9 Addhlonsl Comments: h d7.ely X--ro aqw kkL Aero CAt/e'Vl zed f Applicant -Return all copies to: San Joaquin County Public Health Services i Environmental Health Permit/Services 445 N San Joaquin, P O Boa 2008, Stka, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK If/CASH /RE]CCEEIVED BY (� DATEG , J��-3 PERMIT'NCO. fN1 -2t111EV.lrr+t41 �� 1^r0�., ��S -t�� /rL `L Ly O✓� EN 1422 J V