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APPLICATION FOR PERMIT �,3 u s� - SA IJOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95203 (209) 468-3447 PERMIT EXP,If Ea_I YEAR kROA_DATA J,SSM (Complete in Triplicate) Application Is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in cotapliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San j Joaquin County Public Health Services, Job Address 2Al-, CityAC g222210 Lot Size/Acreage Owner's Name ��. 01 St A ck�.4 `1�A yt't 1 Address a 3 t?T�I C Phone-3 6 J--3 �3 Contractor O l'ykn Address0� 3�- n e'ft'�� No. Phone TYPE OF WELL/ UMP: V NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well D PUMP INSTALLATION la SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANSEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� INTENDED USE TYPE OF WELT PROBL REA CONSTRUCTI CATIONS t `� M Industrial D Open Bottom 0 Manteca Di all Excavation Dia. of Well Casing CJ Domestic/Private 0 Gravel Pack ❑ Tracy a of Casing Specifications M Public i'l Other C3 D Depth Grout Seal Type of Grout — S Irrioation Approx. Depth ❑ Eastern Surface Se stalled by Repair Work Done U Type of Pump H.P. State Work Done ._ Well Destruction D Well Diameter Sealing Material i Depth Depth Filler Material i Depth YPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITIONA DESTRUCTION G INo septic system permitted if public sewer is available within 206 feat.1 Installation will serve: Residence 3ZCommercial^ Other Number of living units: __L_ Number of be dro ms 3 ,^/ Character of &oil to a depth of 3 feet: Water table depth SEPTIC TANK C1 Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well tS .^. Foundation Property Line _ LEACHING LINE Cl No. & Length of lines L10 To al length/size FILTER BED Ll Distance to nearest: Well 1 _ Foundation_ , s Property Line -� SEEPAGE PITS 11 Depth aS/ Size3(.-,, �y6-,, Number / Gn SUMPS LI Distance to nearest: Well /�� Foundation �7S Property Line DISPOSAL PONDS Q , 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 fallowing: "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 must Cali for 11 req red inspe;t:tio .,Co late drawing on revee�rsse�side, � 1r Signed 0111 Title: Date: n- OR 01 AR7MENT USE ONLY ac—"—Application Accepted byNom. , __ - 0 Date Area 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 DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 91V IEEE ArMfOUNT DUE AMOUNT REMITTEO CA K RECEIVED BY /DATE PERMIT'NO.