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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES a ` ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEA-R—FROM DATE ISSUED (Complete in Triplicate) i Application is here made to San Joaquin Count for e pp by q y permit to construct and/or install the work herein described. This � application is made in cmgs .Iiance with San Joaquin County Ordinance No. 549 and 18162 and the Rules and Regulations of San in -Job Address County Public Health Services. /� ., ----- {. - wi� '_\_/sD_ City Lot Size/Acreage Owner's Name j Address � � Phone �v -- _- -� - - FyContractor �dreSS S 9 J License No. ✓V Phone / h TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM AEP IR ❑ OTHER ❑ Monitoring Well C] d DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE �'"r� t FOUNDATION A ICULTURE WELL OTHER WELL ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CONSTRy TION SPECIFICATIONS L1 industrial ❑ Open Bottom D Manteca Dia. of/ell Excavation r Dia. of Well Casing N Ocmesfic/Pri at° ❑ Gravel Pack ❑ Tracy Casing_ Specifications I'I Public F1 Other n Delta I Dep _of-GFo-bt`Seal `0— Type of Grout I I Irrigation Approx. Depth I i Eastern i S ac Seal Installed by Repair Work Done ❑I•. Type of Pump H.P. i State Work Donee ' Seali Material A Depth- + �f Well Destruction ❑ Well Diameter Depth )tiller Material"&,Depth �\} TYPE OF SEPTIC WORK: NEW INSTALLATION ! REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is, available within 200 feet.) \ Installation will serve: Residence s Commorcla 6, 'thaT. - Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacit No. Compartments PKG. TREATMENT PLT.❑ v` 'Method of DispossI w: Distance to nearest: Well �Q Foundation__/_0 -Property Line• ,1 LEACHING LINE C1 No. I1 Length of lines T al length/size FILTER BED ❑ Distance to rfsarest: Well 00 Foundation Property Line S SEEPAGE PITS I I Depth Sire r Number i SUMPS LI Distance to nearest: Wali Foundation Pro rty 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 y 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 i employ any person in such manner as to become subject to workman's compensation Paws of California." Contractor's hiring or sub-contracting signature J certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shad employ persons subject to workman's compensa- tion laves of California." The applicart must call-fo required in pgctions. Complete drawing on reverse side. S Signed X Title: _- - -�,��,. !•,_---- Date: �) RMDEPARTMENT USE ONLY - Application Accepted by -"�"CegapA IfuV .t AA,A ti.•._, Date P"tArea �?•S, S r - ,n_' h Pit or Grout Inspection by Date Final Inspection by �.�" Date_p__� i Additional Comments: ", Adv .LW,4&W a.1- mo- .GurY�E I Applicant - Return all copies o: San Joaquin County Public Health Services � Environmental Health Permit/Services 445 N San Joaquin, P 0 Bort 2009, Stkn, CA 95201 I lFf 0 AMOUNT DUE AMOUNT REMITTED K CEIVED BY DATE PERMIT'N0. j Of 11.2e kx�l EN