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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application 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. Job Address ®CKi /'1 H's SG'N City 7,Y14 C74 Lot Size/Acreage Owner's Name CZ/5' &1 TS Address I E`4 M 11,5A1ye Phone Contractor 14&� c 5,rAl Address License No.yy_Z:_15W1 Phone TYPE OF WELL/PUMP: NEW WELL O WELL7 REPLACEMENT n DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well O 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 L] Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications O ('1 Public El Other n Delta Depth of Grout Seal Type of Grout 1 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material A Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is / available within 200 feet.) Installation will serve: Residence/ Commercial_ Other Number of living units: / _ Number of bedrooms / _ Character of soil to a depth of 3 feet: CL. y Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments b PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line ' LEACHING LINE L1 No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth +�a Size S X/I` Number SUMPS >f Distance to nearest: Well Foundation oV .0 Property Line 1 DISPOSAL PONDS O 1 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 for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mut call for all required inspections. Complete drawing on reverse side. Signed X� �� Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area e Pit or Grout Inspection by Date Final Inspection by Date A:1 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. INFO //11 `*n46 q . EN/324IREV.1in51 S� / �"l -� 1 �"l _0A. a4e2� 6- IT- `� EH 14.26 At