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APPLICATION FOR PRR]dIT + t 7�1 = OA UIN COUNTY PUBLIC HEALTH SERVICES ��" � , a SAN J Q ENVIRONIMTAL UEALTH DIVISION 90 ,p O BOX 2009, STOCKTON, CA 95201A� Z ��' E_ (209) 468-3447 ENViRGf�f`�I N� l_ � �" ;� ! Y E1,31AI111,SER V i C E S (Complete in Triplicate) Application Se hereby made to 811n1 Joaquin County for a permit to construct and/or install the work herein described. This application is mere in cetsplience'vith San Joaquin County ordinance No. 549 and 1862 and the Rules aad Regulstiona of San Joaquin county public Health Services. of Size/Acreage I t City Job Address f phone t Address - Owner's Name1 License No. ��- Phone L Address pESTRUCTION ❑ t of Service Well 0 I` ContraClor WELL REPLACEMENT ❑ Monitoring Well C'} TYPE OF WELLIPUMP. NEW WELL ❑ OTHER Q I I. SYSTEM REPAIR PROP. LINE PUMP INSTALLATION V- * " , pISPOSAL FLD.— SEWER LINES.,-- P1T515UMPS DISTANCE To NEAREST: SEPTIC TANK,---Y--- AGRICULTURE WELL OTHER WELL—�� FOUNDATION �---� I PROBLEM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE TYPE OF WELL Dia. of Well Casing 1 ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Specifications n industrial Te of Casing IODomasticIPrivate 1=1 Gravel Pack ❑ Tracy Type Type of Grout L ❑ Delta Depth of Grout Seal ID Public I'll Other Surface Saul Installed by G Irrigation ___,Approx. Depth d Eastern �R' State Work Dona Repair Work done AA Well Destruction O Well Dia ' N.P. ' � Type Pump Sealing Material i Depth 0) m titer Biller Material ar Depth Depth Tr f k TYPE OF SEPTIC WORK: NEW INSTALt.ATION❑ RI PAIRlADp1TION Cl DESTRUCTION'CI availablerw thin 200 feBjit}ad it public sewer is Installation will serve: Residence___ Commercial — Other — s Number of bedrooms $ L ��Number of living units:, r _ ,�_4.-w w:,- - Water table depth E Character of soil to a depth 3 feet No. Compartments Capacity — I SEPTIC TANK. ©" 1Ype,<Mfg i Method of Disposal- - PKG. TREATMENT PLT. ❑ Foundation. Propeny.Line- - k Distance to nearest: Well _,. Total lengthlsi>:e r LEACHING LINE L`1 No. B Length of lines , I Faundation � Property Line -FILTER'BED n Distance to nearest: Well _ �- Number SEEPAGE PITS I I Depthi I -Size Foundation Property Line. •. L..:�—SUMPS C1-,Distance-to nearest:.. .... Well Y DISPOSAL PONDS ❑ I hereby certify that I have praparod�this application and that the work will be done in accordance with San Joaquin county ordinances, Stale laws, and rules and regulations of the San Joaquin County nature certifies the following: "l certify that in the performance the work for which this permit issued, i Shall not Home owner or licensed agent's sig I employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub contracting signature comilies the following: "I certify that i n;the performance of the work for which this permit is issued,'i shall employ persons subject to workman's compensa- i tion laws of California." The applicant must call�requirjins actions. Complete drawing on averse side. -� f Title: — Date: - Signed F R PARTMENT USE'ONLY Date Area Application Accepted by �7 Q I final Inspection by Date Pit or Grout inspection by Date -- Additional Comments: ` Applicant - Return a.11 copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES R , ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 1 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 CX RECEIVED BY DATE PERMIT'NO. FEE AMOUNT OtIE AMOl1NT REMrTTED CASH � INFO EH1).24 t M. EH:4.16