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e APPLICATION FOR PfiRlrf I T f SAN JOAQUIN COUNTY PUBLIC HEER ALTH SIC$; �V ENVIRONMENTAL HEALTH DIVISION P O 13O% 2009, STOCKTON, CA 95201 (209) 488-3447 R r {Complete in Triplicate) Applicationmpplicatioa is hereby made tp gan, Joaquin County for $ application is made in coliance with San J permit to construct and/or install the work herein described. This Joaquin County Public Health Services, Joaquin CO Ordinance No. 549 and 1862 and the Rules and Regulatione of San Job Address City Lot Size/Acreage Owner's Name Address Phone S Contractor VW �� v dress ,�„__License No. t7 Q l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ Phone PUMP INSTALLAT*N ❑ DESTRUCTIO Out of Service Vell L-1 DISTANCE TO NEAREST:'SEPTIC TAMC. SYSTEM REPAIR ❑ OTHER ❑ Monitoring Vell' U SEWER LINES ___—�____^� DISPOSAL FLD, PROP. LINE FDUNDATlON gGRICULTURE WELL INTENDED USE — - OTHER WELL-- PITS/SUMPS TYPE OF WE'L'L PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open.Bottom ❑ Manteca .G Domestic/Private Ora• of Well Excavation ❑ Grave! Pack � ❑ Trac Dia. of Well Casing M Public y Type of Casing ` VI Other p Delta -- Specifications l CJ Irrigation Depth of Grout S al f Type of Grout --of pum Depth .❑ Eastern Surface Seul Installed by i Repair Work Done U Type o!Pump � � � - ! Wall Destruction 7""'71}`�- H. State Work Done_ Wel! Diameter ! Y Sealing Material i^Depth Depth � Filler-Ms"terla'1"i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ ......AEPAIR/ Ll`DESTRUCTION G fNo septic system permitted if publi w is r available within 200 feat.! Installation will serve: Residence_ Commercial� ~' Number of livingunits: Other _ _ Number Of bedrooms;! Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/.Mfg r Water table depth � PKG. TREATMENT PLT, ❑ Capacity—•-----� No. Compartments g� Distance to n arest: Wall Method of Disposal Foundation______�� property Lino�� f LEACHING LINE Ll No. i Length of lines ' FILTER BED ❑ Distance to nearest: Well_ Total length/siz!Line.Foundation Propertye SEEPAGE PITS 11 Depth 1 , SUMPS Size Number L�I Distance to nearest: WeilDISPOSAL PONDS ❑ Foundation--�� property I hereby certify that I have prepared..this application and that the work wilt be done in accordance with San Joaquin county.ordinances, state laws, and y J ruins and regulations of the San Joaquin'-County" - � Home owner or licensed agent's signature certifies the following: "Icertifyl at 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'Califoini eertifies the following; "I certify that in the performance of the work for which this ermit.i Issued, I shall smplo racfor's^hiring or sub-contracting signature tion laws of Galifor P Y persons subject to workman's compensa- The applicant l !red i n plete drawing on rev a', a + Signed - ilia: `/f f f s I Date: Application Accepted by 4, Cx y E _ r ....__ Date` (l— c� A a 4 Pit or Grout Inspection by �" I ' Date Final Inspection b Additional Comments: Dat Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES' 445+N SAN JOAQUIN, p O BOg 2009, STOCKTON, CA 95201 FEE AMOUNT DUE CK INFO AMOUNT REMITTED RECEIVED BY CASH DATE PERMIT'NO. EH 14.28