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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445p SAN 0 BBOXJ2009, sTpHONE OCKTON1 CA) 420 95201 } rF�R1i T MIRES YE FR M D E S i� (Complete in Triplicate) I permit to construct and/or install the cork herein described. This Application is hereby made.to San Joaquin County for a pe L and 1862 and the Rules and Regulations of n oppliestioa is made in compliance with San Joaquin County Ordinance No. 549 f Joaquin County Public Health Servic€s. I ] � City=. f� Lot Size/Acreage Job Address `r 19 V l� Phone Owner's Name _ Address �� }( sl�3a License No. Address I Contractor Address NEW WELL ❑ WELL REPLACEMENT f] DESTRUCTION ❑ Out of Serviee Well TYPE OF WELL/PUMP: OTHER D Monitoring Well 0 PUMP INSTALLATION ❑ �, SYSTEM REPAIR ❑ x LINES �--�— DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST. SEPTIC TANK �— SEWERPITS/SUMPS FOUNDATION _.---�— AGRICULTURE WELL OTHER WELL TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE —-�`� Dia, of Well Excavation Dia. of Well Casing n Industrial O Open Bottom ❑ Mantec a I Specificationb Type of Casing_ [.l Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of,Grout t Cl Other ❑ Delta 1 '11 I 1 Public l I Eurtace Seul,lnstalled by I I Ifrigation — pth N APprox..Deastern S,^ i r H P Stats Work.Done Repair Work Done ❑ Type of Pump listeriwl al Depth Sealing 1 Well Destruction O , Well Diameter--Piller Material i Depth (� Depthsystem permitted if public sewer is ] TYPE OF SEPTIC WORK: NEW INSTALLATION4 ).'REPAIR/ADDITION DESTRUCTION I l availableseptlw thin 200 feet.) p installation will serve: Residence Commerciale�; Numbir of living units: Number pt bedrooms �� Water table depth Character o1 sola to a depth of 3 fast: ( Capacity—l o i Type/Mfg: ems"' �``� !Zp No. Compartments SEPTIC TANK _ Method of Disposal PKG. TREATMENT PLT.GI r ;��s'e` ` �;f: r /12 0 F40 S Foundation Property Lina��— I Distance to nearest: WeII f L LLD r Total length/si2a LEACHING LINE No. a1 Length of Ilnes- � Property Line �� Number SEEPAGE PITS ❑ Distance to nearest:' Well Sb r Foundation FILTER B£D k Sire �r� l Depth Foundation---ZD— Property Line—Z-L— + Dry� SUMPS CI Distance to nearest: Well DISPOSAL PONDS O j' i I hereby Certify that I have prepared this application and that the work will be done in accordance�+vith San Joaquin county ordinances, state laws, an rules and regulations of the San Joaquin CouatY ollowing; "I certify that in the pertormance of the work for which this permit is issued, Home pvmsr of licensed agent's signature certifies the fl signature shall not employ any person in suchI anultraas to s n thebecome performs ecof the wto rork foswhich-this compensation c�is issued,of California." shallIsmploY_peotons��bject to wprktme . compenss certifies the ipNpwing:" fY._ . _ -.�-_. tion laws'of California." The applicant mu 11 for al�.required in ctions. Complete drawing on reverse side. /7 -/7 !/ Title: 1/,!�/C�/ Date: / Signed OR DEPARTMENT USE ONLY —7 Date Area Application Accepted by Zo Pit or Grout inspection by Date�--- Final Inspection by � Data AdditionalComments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services j, 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 I CK PERMIT N0. FEE RECEIVED BY OATS W IEEE AMOUNT DUE AMOUNT REMtTTEO /y Iv _� . EH 13-24 111 1 i151 ��'�( _ A 4 Q,* — EFl 14.1e