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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 work herein described. This application is made in compliance with San Joaquin County Ordinance No.�549Undj8162 and the Rules and Regulations of San Joaquin County Public Health Services. �MJob Address n �"z r �'� City � Lot Size/Acreage Owner's Name Address / G ` Phone Z `z "&I ConUactor t� , 0,SS_JVd1e" ss 19 / License N J �1 Phone Fy TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REP IR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A ICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CONSTR TION SPECIFICATIONS [_l Industrial ❑ Open Bottom El Manteca Dia. of ell Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack O Tracy CasingSpecifications I"I Public 1-1 Other [l Delta Dep of Gibut Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern S lac Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Seals Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION (V REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is �� available within 200 feet.) \ Installation will serve: Residence" Commercial cher Number of living units: Number of bedrooms' Character of soil to a depth of 3 feet: Water table depth ( ` SEPTIC TANK ❑ T c �� ype/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well �Q "Foundation —/� Property Line G T LEACHING LINE ❑ No. b Length of linea ^' �ength/size �l FILTER BED C1 Distance to nearest: Well CIL, `� !Foundation Lr Property Line SEEPAGE PITS 11 Depth Sire� Number SUMPS LI Distance to nearest: Well Foundation Prorvrty 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 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 applican must call for required in pections. Complete drawing on reverse side. Signed ` Title: L� .yl ' Date: 3 4 F R DEPARTMENT USE ONLY / ` C Application Accepted by ..A w +t +rs Date lP -�1—� Area Pit or Grout Inspection by Date Final Inspection by A0 Y0wuljk_a),c Date Additional Comments: t WA ,(p 0"� ci- Applicant - Return all copies o: 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 YIC K CEIVED BY DATE PERMIT N0. INFO EH 1324(REV.1/x 5) C�f9 C (';o EH 14.26 �J'\