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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES1 YEAR FROM D TEISSUED f (Complete in Triplicate) .i Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in ec4liance with San Joaquin county ordinance No. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,I Job Address ZZIN-1. � City. i Lot Size/Acreage 1 j*- f Address a3 � Phone Owner's Nem Contractor Address bag"7 � License No. 3 �5 Phone r—` TYPE OF WELL/PUMP: ' NEW WELL ❑ WELL REPLA MENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION E3 SYS REPAIR ID 4 OTHER ❑ „ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'YFLO. _PROP."LINE FOUNDATION AGRICULTURE WELL _'OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing Cl Domestic/Private ❑ Gravel"Pack ❑ Tracy Type of Casing Specifications on 1'1 Public I-1 Other nDelta Depth of Grout Seal „r Type of Grout I I Irrigation ___Approx. Depth I 1 Eastern Surface Seal Installed by k Repair Work Done L] Type of Pump H.P- ---=- State Work Done _ Well Destruction ❑ Well Diameter Sealing Material &'Depth Filler Material i Depth Depth TYPE OF SEPTIC WORK: NEW-INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I iNo septic system permitted if public sewer is I available within 200 feet.) f Installation will some: Residence� Commercial Other Number of living units:. Number 9tbodroo Character of soil to a depth of 9 feet: NzD [ ,,W�,�ter table depth ' SEPTIC TANK. ❑ Type/Mfg Copacity't�(rr No• Compartments' i PKG. TREATMENT PLT.Ll Method of Disposal 1 Distance to nearest: Well Foundation Property Line . JP I' l LEACHING LINE 11� No. 6 Length of linea - Total length/size _ FILTER BED Cl Distance to nearest: Well �.�`Foundation Props rty Line SEEPAGE PITS Depth Size_ Number �---SUMPS Ll Distance to nearest: Well Foundation Property Lina ` DISPOSAL PONDS ❑ 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 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 shall 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 t;1146. s of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mus call for all required o7-- Title: to drawing on rev r side. ��J Sig Date: FOR DEPARTMENT USE ONLY A Il tion Accepted by Date L Area Sk/Wii Pit r Grout Inspection by Date — Final Inspection by 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 FEE AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE I PERMIT'AFO. INFO . EK 1124(1111Y.tical S [ `.� -�'�^^1� -�.3- / �," .�✓ EH 1!•76