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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . ENVI�TAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PEMIT EXPIRES I YEAR 9M DATE ISSUEI] (Complete in Triplicate) Application is hereby srade,to San Joaquin County for a permit to construct and/or install the work herein described. This application Is made in coupliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 2222,2 AXt "T&__ City =,642 ' Lot Size/Acreage g V Owner's Name j blAddress j v Contactor 6bta0ad!LN=• Address License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout 0 loigalion Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H,P, State Work Done _ Weil Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth ' TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION LT DESTRUCTION M (No septic system permitted if public sower is available within 200 feet.l Installation will serve: Residence t�Commercial— Other Number of living units: .. Number of bedrooms -S - t l Character of soit to a depthh f 3 feet: Water table depth kvo SEPTIC TANK. �f Tyge/Mfg Capacity— -0�© No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest. Well r T Foundation . _ Property Line- -7J1) _ LEACHING LINE No. & Length of lines _ 2- Total length/size FILTER BED n Distance to nearest: Well :Z(2' Foundation - 7 _ _ Property Line(f It _ SEEPAGE PITS I�Depth � Sire � Nugnber Z- SUMPS L1 Distance to nearest: Well � a} Foundation__112� Property Line ajw 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 fpr which this permit is issued, I shall employ persons subject to workman's compenss• tion taws of California." The applicant must call all required inspectio Complete drawing on reverse side. Signed Title: -� -, Date: ll� ENT_ USE ONLY Application Accepted by Data . 11�_�- Area 11 It 2--- tor Grout Inspection by Date �FinaE Inspection by Datt��tJ Additional Comments: Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO Em A- AMOUNT DUE AMOUNT REMITTE Ct( RECEIVED BY D TE PERMIT/N7O. . EH 24IBEV.oihS!