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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONhMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PEMIT EXPIRES FROM D T I SU (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This I application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. i .lob Address ((City Lot Size/Acreage ` e3-• r d� Owner's Name L Address Phone 5447 Contractor 461_w[� Addres� d�- Li�o. Phone i TYPE OF WELL PU NEW WELL ❑ WELL REPLACEMENT I] DESTRUCTION Ll Out of Service Well ❑ ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ar Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL ILD. PROP. LINE FOUNDATION � AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia, of Well Casing 1k Domestic/Private ❑ Gravel Pack L3 Tracy Type of Casing_ Specifications 1'1 Public M Other Cl Delia Depth of Grout Seal Type of Grout f I I Irrigation _Approx., Depth I 1 EasternSurface Seal Installed by Repair Work Done 1. Type of P. P-A.ALk- H.P. i S t Work Done Well Destruction ❑ Wel! Diameter Sealing Material A Depth Depth hiller Material A Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is > - available within 200 feet.) s Installation will serve: Residences Commercial_ Other r Number of living units: Number of bedrooms \ Character of toll to a depth of 3 feet: Water to SEPTIC TANK: ❑ Type/Mfg } Capacity No. ComaC ss PKG. TREATMENT PLT. ❑ Method Alma VED Distance to nearest: ' Well Foundation Property Line J PA 1130 � Y LEACHING-LINE' EACHINGLINE ❑ No. & Length of lines Total length/size SAN I pu5LIU""W FILTER BED ❑ Distance to nearest: Well Foundation Propepy, "r- AI t1�1 SEEPAGE PITS I I Depth Size Number s -SUMPS. =la Distance to nearest:-f. Well r=--r- ,Foundation Property Line A DISPOSAL PONDS ❑ I 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Tawe of California." t. t The applicant cpust call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FO SPAR NT k Application Accepted by Date L Arj9S Pit or Grout Inspection by Date Final Inspection by Additional Comments: ~ Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services J 4 445 N San Joaquin, P 0 Boa 2008, Stkn, CA 95201 FEE AMOUNT OU AMOUNT REMITTED iNFOCASH R EIVEO BY O E PERMIT'NO. f 3 r EN 1.1.21(REV.i/M e f r � yllffk/ i EN 1 .2a