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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 0 BOX 2009, STOCKTON, CA 95201 t PERMIT EXPIRES 1 TE FR M DATE ISSUIM (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in cea>pliance with San Joaquin County Ordinance No. 549 and 11362 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name -Address Phone i Contractor Address .� �� -� License No. G1�2�iphone TYPE OF WE /PUMP: NEW WELL ❑ WELL AEPLACEMENT ❑ DESTRUCTION ❑ Out of Service Kell ❑ PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ZZPA SEWER LINES 52 g2 "— DISPOSAL FLD. ,ZZQT PROP. LINE jg2f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom., © Manteca Dia. of Welt Excavation Dia. of Well Casing ,4. E) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ G Specifications f'] Public I-1 Other'- ` FI Delta Depth of Grout Seal IL/ Type of Grout v ['I Irrigation —Approx. Depth I I Eastern _ Surface Seal Installed by c- Repair Work Dona 0 Type of Pump H.P. S to ork Done Well Destruction 0 Well Diameter Sealing Material i Depth "-L- Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION 1 I DESTRUCTION I I fNo septic system permitted if public.sewer is available within 200 feet.? Installation will serve: Residence-.._ Commercial,_ Other Number of living units: Number of bedrooms Character of sob to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Ca acit P Y No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size 4N. FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I 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, end rules and regulations of the San Joaquin county Home owner or licensed pmt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shelf not f 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 performanee of the work for which this permit is issued, l shall employ persona subject to workman's compensa= don laws of California." The applicant t f all r cY a. mplete drawing on re rse side, i Sign ad Title: CG Date: i - ! FOR DEPARTMENT USE ONLY y� Application Accepted by Date Z S Area Pit or Grout Inspection by Date Final Inspection byData 7-F 3 Additional Comments: Applicant - Return all copies to: 3a Joaquin County Public Health Services Environmental Health Permit/Services 2� ( � -f-7- 445 N San Joaquin, P 0 Box 2 , n, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK DATE PERM17'NO. I 9Y INFO � CASH EJ4 13-24 IREV.t rt ` + EH 11.2! K 51 (til. l �'�� t � -