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APPLICATION FOR PERMIT � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION + P O BOX 202 , ST 883447 CA 95201 4,W\� QtV (Complete in Triplicate) ll vork Application to hereby made to San Joaquin County Or for a pelt nancenNO- 549and62sa d eherein the Rules aadRegulationsdof Sans application is made in compliance{with San Joaquin County Joaquin County Public Health Services. A. Lot Site/Acreage d f� City FQ .lob Address � j �U (hone � Address i Owner's Name j� License No. Phone 7 Contra f:. Address ' ` NT n pESTRUCTfON ❑ Out of Service Well ❑ C WELL REPLACEME Monitoring Well ❑ 5 TYPE pF WELL/PUMP: NEW WELL ❑ OTHER ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR PROP LINE DISPOSAL Flp,�—• � SEWER LINES _ —�--- PITS/SUMPS DISTANCE TO NEAREST: SEPTIC TANK —�---- AGRICULTURE WELL OTHER WELL FOUNDATION -- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS.,, Dia. of Well Casing ❑ peen Bottom ❑ Man teT ce Dia. of Well Excavation in Industrial Type of Casing Specifications Domestic/Private ❑ Gravel Pack C] Tracy Type of Grout I,I Other ❑ Delta Depth of Grout Seal Public \ .w Appror': De th ❑ Eastern Surface Seat Installed by U irrigation H P State Work Done (JI) Repair Work Done Type of Pump — Sealing Material i Depth "v Well DiameterFillerDepth Destruction 1 i Wait Dest ,� Filler Materia - Depth permitted it public sewer is available within 200 feet,] TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIRlADDITION L:I pESTRUCTION G ffJo septic system pe installation will serve: Residence�` C �'mercial Other .--- s �n Number of living units: Nur+tiber of bedrooms ��Y = - � sWater table depth I � i r Character of soil t0 a depth of 3 test: I Capacity =} No. Compartments SEPTIC TANK © Type/Mfg Method of Disposal PKG, TREATMENT PLT. 0 Foundation ~ Property Ulna Distance to nearest: Well �f Total length/size LEACHING LINE 0 No. & Length of lines f FILTER BED C1 Distanctl to nearest: Welt Foundation �— Property Line — Number SEEPAGE PITS I I Depth I ' Size tom\ Foundation Property Line SUMPS Ll Distance to nearest: Well �— ; DISPOSAL PONDS. ❑ A 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 L. ' 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 shalt net neon:subject to workman's compensa• employ any person in such manner as to become subject to workman's compensation laws of Csliforni& Contractor's hiring or subcontracting signature certifies the following: •'I certify that in the performance of the work for which this permit is issued, I shall employ pe i tion laws of California.,. �. The applic must cal for all required in ions. omple rawinq o se side, 1� Title: f — Data: i Signed1. FO DEPARTMENT USE ONLY Da Area j Application Accepted by t �� Dat � -- �` Date_,�� ...-- Final,Inspection by + Pit or Grout Inspection by Additional Comments: r SRVICES Applicant — Return all copies to: ENVIRONMENTALJOAQUIN �HEALTHUNTYUBLIC DIVISIONLTH pERMIT/SERVICES 445 N SAN JOAQUIN, p O BOX 2009, STOCKTON. CA 95201 AMOUNT REMITTED CK AECEIVEO BY DATE PERMIT'NO. FEE AMOUNT DUE CASH INF . EH 13.24 I11EV.N r n 51 5.�� ti`�-"� q.Q