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{ APPL I CATION FOR PERI[I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 ceelpliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ' s�y'`f ��YA ity /T7'/1'�Y Lot Size/Acreage Owner's Name O4(/c 0f/7'19lvrQ Address Y19 DOs h/tS oN 2 Phone 4 rR- Contractor _Address d6VA 66 00f0,47 License No. Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well Q 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 Cl 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 I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout Q I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by QVQ Repair Work Done U Type of Pump H.P. State Work Done Woo Destruction O Woo Diameter Sealing Material A Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if 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: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. b Length of lines Total length/size �ll FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth 10 Size .f X Jz ' Number SUMPS Al Distance to nearest: Well Foundation �SProperty Line !fl � v DISPOSAL PONDS O L e"X_7,� I hereby certify that I have prepared this application and that the won 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 subcontracting 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 MU31 call for so required inspections. Complete drawing on reverse side. Signed X Title: Date: OR DEPARTMENT USE ONLY Application Accepted by Date 2— Area -2/6 Pit or Grout Inspection by Date Final Inspection by Date 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 INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. FEE. EM 13.24(REV.I i R 51 S 19 EH 14.26 �L �•GG7! {