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i APPLICATION FOR PERMIT � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 &WIT MMIRAS I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby meds to San Joaquin County for a permit to construct and/or install the work herein described. This application is Stade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San I Joaquin Cour y Public Health BeMo s. Job Address og, City, hot Size/Acreage Owner's Name : Address t] 5 a V� Phone l ! Contractor ' dja Address License No.1��Phone ! TYPE OF WELIi/PUMP: NVh WELL ❑ WELL REPLACEMENT _ DESTRUCTION ❑ out of Service Well h PUMP INSTALLATION O SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ ' 1 DISTANCE TO,NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } INTENDED USf' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial r }.❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private f !E-0-Gravel-PackL7 T : racy--.,, Type of Casing_ Specification �1 Public !1 OtherCl Delta Depth of Grout Seal L'' _ T of Grout � I 1 Initiation Approx. Depth I I astern rface Seal Installed by Repair Work Done ,U I'Type cf Pomp---_ '' - " �H.P. � � -- —_ State Work Done_ � Well Destruction ❑ Well Diameter tf Sealing Material i Depth t I 1Depth_ a Sn.I _ Filler Material-:i Depth { vv f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is r � available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Numberjof bedrooms ti Character of WIN to a+th of 3 feet: 1 Water table depth r SEPTIC TANK. 0 Type/Mfg _I --- 1 ,Capacity No. Compartments 11 PKG. TREATMENT PLT.C) I I/ Method o ` Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. S Length of lines Total length/size R 1992 FILTER BED O Distance to nearest. Well Foundation Property Lie s;Li hl'gY {{ r> SEEPAGE PITS I I Depth—:�� ` Size / Number ENVROVMENTA! IiEAi T"ri UfYiSiQ?�! SUMPS f LI•` Distance'to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ,e ;.r I hereby certify that I have prepared this application and that the work willtbe done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin-County ... i I 1P 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 perso such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifisi tlii i R Tc rtify t sit-in tthe ps ormrfime of the workk for ww ich this permit is issued, I shall employ persons subject to workman's compensa- tion laws o Cali la.,. The applicsn t ca41 for all req it inspect' s Complete drawing on reverse side. LESigned Title: Data:Jv FOR DEPARTME USE ONLY Application Accepted by 19Data Area Pit or Grout Inspection by Date Final Inspection by'� Date Additional Comments: 4, ,. Applicant - Return all copies,to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P Box 2009, Stkn, CA 95261 IPfO AMOUNT DUE j AMOUNT REMITTED CK ECEIVED BY DATE PERMIT NO. ♦ EH13.24 MEV,t i h 61 I EH 14.26 !! / V "