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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON[, CA 95201 i PERM T EXPIRES 1 YE FR M D T'E ISSUED (Complete in Triplicate) Application is hereby made to San Joa4uin county for a permit to construct and/or install the work herein described. This County ordinance No. 549 and 1862 and the Rules and 33-f 3 -- San application is made in compliance with San Joaquin Joaquin County Public Health Service 133-1_31 •�1-ro � City Lot Size/Acreage lob Address e Phone Address ' Owner's Name ce NO n t I a c I or Address License No., Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out Monitoring Well C] PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ SEWER LINES _. DISPOSAL FLD. PROP. LINE DISTANCE TJ NEAREST: SEPTIC TANK -� AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION �-- INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia of Well Casing CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Typo of Casing_ Specifications Cl Domestic/Private Cl Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout I'l Public Cl Other n Delta I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Stats Work Done .,-.. Repair Work Done Ll Type of Pump H.P. S4taling Material B Depth Well Destruction ❑ Well Diameter Filler Material i Depth Depth TYPE OF SEPTI WORK; NEW INSTALLATION I 1 ,FIEPAIR/ADDITION i I DESTRUC710 iNailabetic system w Thin 200 feet.) it public sewer is Installation will serve: Residence— Commercial— Other tY Number of living units: Number of bedrooms Water table depth f Character of sol to a depth of 3 feet: - No. Compartments SEPTIC TANK ❑ Type/Mfg capacity Method of Disposal 1 PKG. TREATMENT PLT.❑ Distance to nearest: Well Property Line Foundation _ LEACHING LINE Cl No. b Length of lines Total length/size Property Line FILTER BED L) Distance to nearest: Well Foundation I SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: well-.- �Foundation--: Property Line 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 I rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: 11 certify that in the performance of the work for which this permit is issued, 1 she 11 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 the performance of the work for which this permit is issued,I shall employ parsons subject to workman's compensa- tion laws of California." The applicant must�C—Sllfoall required in coons. Complete drawing on/re#v�erse side. Igned itle: .� Date: F DEPARTfMENT USE ONLY v a Area �L Date Application Accepted by Date Final Inspection by Date Pit or Grout Inspection by *4A3 Additional Comments: 6;�4 Com' . I Applicant - Return all copies to: Environmentalan joaquin oHealth Permit/Services unty Public Health vices 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DA PERMIT'NO. INFO �� . EH 1121 IREV,vRal \ a p (� fH 11•Za aJ i