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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I TNVIRONIMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YFIAR FROM DATE ISSUED (Complete im Triplicate) Application is hereby made,to San Joaquin County for a permit to -construct and/or install the work herein described. This application is made in compllanceJvith.San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public�Heealth Services. Job Address — L .Wt: �(p�Ql City. Lot Sire/Acreage i, Owner's Name Cy, �p d, 0 Address T l `l �f/i (lout 44 Phone Contractor Address 3#-& S Kr lip f License No.?At 2i: . Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 177 DESTRUCTION Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'l Public - (-1 Other n Delta Depth of Grout Seat Type of Grout p I I Irrigation Approx. Depth i I Eastern Surface Seal Insulted by N Repair Work Done ❑ Type of Pump P. State Work Done_ Wed Destruction Well Diameter —fat' sealing Material i Depth Depth' Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I # DESTRUCTION I i lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence 1 Commercial— Other Number of living units: Number of bedrooms Character of sod to a depth of 3 feet. f Water table depth SEPTIC TANK. ❑ Type/Mfg I Capacity Na. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well _ Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED _ ❑ Distance to nearest Well :`Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance totneerest: Well Foundation Property Lina 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 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 shad not employ any person in such manner as to bilcome 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 iri issued, I shall employ persons subject to workman's compensa- tion laws of California." _ • .4 Thea - -. j pplicant s call for all r it inspections. Complete drawingon r*Arse side. SignTide: Date: Signed F DEPARTMENT USE ONLY Application Accepted by _�0��4jA .� ,a ..._ Date Ph or(trout Inspection by Date Final Inspection by Oatit� O Additional Comments: Applicant- Return all copies to: - San Joaquin County Public Health Services C Environmental Health Permit/Services ' 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASCy 1 H RECEIVED BY DATE PERM17'NO. • EYI 13.21 IIIEV.1/M 5) /�Ir 0 I �� eM ta•�s Cf/ if /