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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 PER—MIT EXPIRES YE ROM D T U (Complete in Triplicate) ' t and/or install the work herein described. This all Safi Joaquin County for a perms t to construe a of San Application is hereby application is made is canplisace,vith inn Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regula on Joaquin County Public Health Services. kTFl P Lot Sixe/Acreage City Job Address rPhone PJ� CS£ E p �, � net's Name *rl` Address � ^ c*-License NaPhone , *Contractor L-' Addiess pESTRUCTION ❑ put of Service well n ANEW WELL Q`! WELL REPLACEMENT n OTHER O Monitoring TYPE Of WELL/PUMP: t - +,;- SYSTEM REPAIR ❑ PUMP INS IALLATION ❑ `� v f. . .. DISPOSAL FLD. PROP. LINE j SEWER LINES --� PITSISUMPS _ l DISTANCE TO NEAREST: SEPTIC' ��-- AGRICULTURE WELL OTHER WELL�-- FOUNDATION'—� INTENDED USE TYPE OF WELL PROBLEM AREA` CONSTRUCTION SPECIFICATIONS Dia. of Well Casing LI El❑ Open Bottom ❑ Dia. of Weil Excavation Manteca' i } �- Specifications— [] Tracy aType of Ca'sing— I rCl Domestic/Private ❑ Gravel P�k } pepth of Grout Seal Type of Grout I'1 Public [:1 Other fl Deltj I i I Irrigation —Al Depth I I Esstem Surfaee�5au�nstalled by �. H P Stats Wtir�:Done 1 Repair Work Done U Sealing Type of Pump Material i Depth., I Well Destruction O Well Diameter tiller Material i Depth Depth _ ' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION # I pESTRUCTION available�withiri 200 feet.lsd it public sewer is f t Installation vi serve: Residence Commercial'—' Oilier — r Number of living units: Number of bedrooms Water table depth Character of soli to a depth of 3 feet: F No. Compartments i SEPTIC TANK. 0 Type/Mfg Capacity f 1� � Method of Disposal PKG. TREATMENT PLT. Property Line k Distance to nearest: Well Foundation • '"�- Dial length/size LEACHING LINE 0 No. & Length of lines Property Line FILTER BED Cl Distance to nearest: Welt Foundation - SEEPAGE PITS I I -Depth'1 Size Number '� L! Distance to nearest: We Foundation 1 Property Line -- SUMPS r 1 DISPOSAL PONDS ❑ I I I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end 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 aha 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 compenss- tion laws of CaUfwnta." applicant must call for all requited ' spettions. Complete drawing on reverse side. ! . 3 aijr. y Spm F USE ONLY R DEPARTMENT U _ .,...�...� z �. .. Date roe �'T,� 2- + Application Accepted by Pit or Grout inspection by Date Final Inspection Date a Additional Comments: li Applicant - Return all copies to: San Joaquin County Public Health Services Eavironmental Health Permit/Services 445 N Saa Joaquin, P O Baa 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY D TE PERM17 N0. INFO . EM 1}y1lREY.�/NS1 �- EH 1140