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APPLICATION FOR PERMIT i <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES1401rr1ENVIRONMENTALHEALTHDIVISION <br />445 N SAN JOAQUIN, PHONE (209)468-3420 <br />i, P 0 BOX 2009, STOCKTON, CA 95201 <br />PERMIT EXPIRESY FR M DATE SUED <br />Complete in Triplicate) <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br />j <br />application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of SanJoaquinCountyPublicHealthServices. <br />Job Address City Lot Size/Acreage <br />Owner's Name ddress 4Phone ZJ (r <br />Contractor Address License No. Phone <br />TYPE OF WELL/P MP: NEW WELL 0 WELL REPLACEMENT .. DESTRUCTION Out of Service Well <br />PUMP INSTALLATION SYSTEM REPAIR OTHER Monitoring Well S <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION'' AGRICULTURE WELL OTHER WELL PITS/SUMPS l <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />C7 Industrial Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br />CI Domestic lPrivate Gravel Peck Tracy f Type of Casing Specifications <br />t <br />f'1 Public fl Other Cl Delta r Depth of Grout Seal Type of Grout dQ <br />I•I Irrigation Approx..Dapth I I Eastern Surface Seal Installed by <br />Repair Work Done U Type of Pump. H.P; State Work Done — <br />Well Destruction O Well Diameter` Sailing Material i Depth <br />Depth driller Material i Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION Iff REPAIR/ADDITION i I DESTRUCTION l I (No septic system permilted if public sewer is <br />I available within 200 feet.1 <br />Installation will serve: Residence_L_ Commercial_ Other . ,. <br />E tNumberoflivingunits: Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK. Type/Mfg Capacity -0 d No. Compartments <br />PKG. TREATMENT PLT. p <br />id Method of Disposal <br />Distance to nearest: Well/' 6 Foundation Property Line <br />LEACHING LINE No. & Length of linesg Total length/size <br />FILTER BED Distance to nearest: Well jL_Q Foundation _!Q Property Line _!c=— <br />7 <br />r <br />SEEPAGE PITS I I Depth Size Number <br />SUMPS LI Distance to nearest: Well/ --- Foundation I j2 4 Pro erty Line - !6 d <br />DISPOSAL PONDS <br />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, andrulesandregulationsoftheSanJoaquinCounty <br />Home owner or licensed agent's signature certifies the following: "I certify that in Mie performance of the for which this permit is issued, I shall notemployanypersoninsuchmannerastobecomesubjecttoworkman's compensation laws of California." Contractor's hiring or sub-contracting signatureeerlifiesthe1`0140wing: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa-tion laws of California," k <br />The appl!cent"at call for all reqyM inspections. Co lete drawing on reverse side. <br />Signed Title: Date: a <br />F R DEPARTMENT USE ONLY <br />Application Accepted by DeteArea <br />Pit or Grout Inspection by <br />61 <br />Date nanepection by Date <br />Additional Comments: F <br />Applicant - Return all copies. to: San Joaquin County Public Health Services <br />Environmental Health Permit/Services <br />H 445 N San Joaquin, P O Box 2o09, Stkn, CA 95201 <br />FEE AMOUNT DUE AMOUNT REMITTED CK <br />RECEIVED BY DATE PERMIT'NO.INFO CASH <br />Ily , oEM12-II[NEV.I/sal C?El!11.2E