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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 X XM FLQM DATE IgSURD (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 ttmde i Compllez►ce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health ervices. &_6k) Job Address + City Lot Size/Acreage ner's Na IOU— GNk� J Phone 4— 4-- �04- 1W �J�j f IIx �res No. s' Phone q. TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALL.ATI 4C3 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE-OF WELL—'PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing tic/Private ❑ Gravel Pack ❑ Tracy p Type of Casing_ Specifications I'1 Public 1-1 Other ❑ Delta J Depth o1 Grout'Seal— -- Type of Grout I i Irrigation _Approx. qe I I stern uriace Seal Installed by Repair Work Done U Type of Pum H.P. 1 2 4 _ State Wor Well Destruction O Well Sealing Material &.DepthAAJO 1 Depth Filler Material A Depth I �J' f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I # DESTRUCTION I l 1No septic system permitted if public sewer is C — available within 100 feetJ rj Installation will serve: Residence_ Commercial T Other } Number of living units: Number of bedrooms Character of sag to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 ragulations of the San Joaquin County _ __ Home owner or licensed agent's 94 iii 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 workmen's compensation laws of CsIilor ' Contrector's hiring or sub-contracting signature certifies the following: "1 certify th t in the psrlormence of the work for which this permi is issued, I all employ persons subject to workman's compenss- tion laws of nie-" The applice mu call t ed in ctiorts. Complete drawing on r arse ' Sp Title: Date: A� FOR EPARTMENT USE ONLY Application Accepted by _ _ C'_ `11'ul )�L Data � - Area Pit or Grout Inspection by Date Final Inspection by A LJw r Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CAQQSH RECEIVED BY 1DATE PERMIT'NO. (fb • FN1}21t11EV.1/N5) �V �=ate �1Ci� t rt a-m