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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION " E " EIVID P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 P IT EXPIRES_ l YEAR ISM DATE ISSU$D MAY - (Complete in Triplicate) ENVIRONMENTAL HEALTH Application Is hereby trade to San Joaquin County for a permit to construct and/or install ttie Yi�t�eF � fi ,Tl�gd. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Healt Services. Job Address _ r� �, Cit Lot Size/Acreage Owner's Name ." Address Phone Conlraclor Address U License No.a6,5WL Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT - DESTRUCTION ❑ Out of Service well PUMP INSTALLATION 0 SYSTEM REPAIR V OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t. U Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Specifications ` M Public I'll Other 0 Delta Depth of Grout Seal Type of Grout N4 _Approx, Depth !!rl Eastern Surface Seal Installed by /Repair Work Done A Type of Pump _��,Q,fajfC H.P. hd State Work Done r Well Destruction O Well Diameter --Sealing Material & Depth Depth �O r Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION Cl (No septic system permitted if public sewer is available within 200 lost.) Installation will serve: Residence^ Commercial_ Other f Number of living units: Number of bedrooms Character of poll to a depth of 3 feet: Water table depth SEPTIC TANK .fl Type/Mfg Capacity No. Compartments J PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines. Total length lsixe FILTER BEDS n Distance to nearest: Well Foundation Properly Lina SEEPAGE PITS 11 Depth Site Number SUMPS _ Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑, I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Iaws, 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.wock for,which-this-parrnii-is-issued-1-shall-not-- employ any peraan in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the foll 'ng: "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 li rnis." The'appli ust call for all r Q 'red inspsc ' ns. Complete drawing r v rse side. Signed Title: Date: FOR DEPARTMIE T USI ONLY R. Application Accepted by Date `5 Area y- Pit or Grout Inspection by Date Final Inspection by Date L� Additional Comments: + _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESct5 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICESo F 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 0 fg�-`,V_�., EEECK IT IAMOUNT OVE AMO/UNT.REMITTED CASH RECEfVEd'8Y DATE PERMIT'NO. it`d` . EN 19.2 IREV.r i w s1Jr f I J"` �`J�'� �• Ex 111.28 r