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APPLICATION SAN JOAQ IN COUNTY PUBLIC HTALTH SERVICES I BONMFsNTAL HEALTH DIVISION 445 N S JOAQUIN, PHONE (209)46$-3420 AID # l 5 O % 2009, STOCKTON, CA 95201 FACIRES 1 YEAR FROM DATE ISSUED l� _ &1 Complete in Triplicate) V, ' - qu n Ity for a permit to construct and/or install the work herein described. This ce -it San Joaquin County Ordinance No. 549 and .2862 and the Rules and Regulations of San oaqula County Public Health Services. �_yc�._.� Job Address / rt CityLot Size/Acreage ��(+ Ownei s Name A"" Address _ Phone 6 Contractor 1^ Address ! License No. Phane TYPE OF WELL/PUMP: NEW WELL ❑ WELt- REPLACEMENT ::1 DESTRUCTION ❑ Out or Service Heli 0 PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER,LINES DISP AL !tD. PROP. LINE FOUNDATION AGRICULTURE WELL HER WELL PITS/SUMPS ._ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC SPECIFICATIONS l^ Industrial ❑ Open Bottom ❑ Manteca Dia. of ell xcavalion Dia. of Well Casing F Domestic/Private ❑ Gravel Pack Ll Y'acy T of C ing_�- _ Specifications i Public 17 Other M Dela Depth Grout Seai Type of Grout i i Irrigation _ Approx. Depth i Eastep, Surf Seal Insralled by Repair Work Done U Type of Pump �N.P __� State Work Done _ Well Destruction ❑ Well Diameter Sfa llaterial & Depth Depth Filler Haterial''i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR:ADDITION TV. DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feel.) Installation will serve: Residence - Commercial _ E}ual, I� Number of living units: Number of bed r ms Character of soil to a depth of 3 feet: Water table depth �4 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation _ Property Line (� LEACHING LINE L1 No. & Length of lines _ Torp�l l/en-gth/size FILTER BED Cl Distance to nearest: We Faunaation �!"JG Property Line SEEPAGE PITS ( I Depth Size N� mber SUMPS U Oiblance to neaFest: WaIYIV4iM Foundation y� 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 lows;and rules and regulations of the SanJoaquin 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 workmen's compensation laws of California." Contractor's hiring or sh-contracting signature certifies the following: "!certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion 4sws of Cslilgmla." The applicant mus call for dM r red in tions. Complete drawing on reverse side. .1. ",i Signed X - Title: Date' , FOR DEPARTMENT USE ONLY Application Accepted by dt Date Area Pit or Grout inspection by Date Final Inspection by Dste jr 3 4 Additionei Comments: ---~- Applicant - Return all copies to: San Joaquin County Public Health Services Environmental 11cJoaquin, h 0 Bo t2009, cos rt O s� r 445 N San Joaquin, P 0 Boz 2009, Stkn, CA 95201 {1 } INF, AMOUNT DUE AMOUNT REMITTED CASH RECEIVEO BY DATE EH 4•2a fREV.ria 6> —/ � L `� � ! �(' �� -1 V�J t!