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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION '! 445PN0 BOX 2009TNSTOCKTON`2CA)95201420 pAyMEN"�' s RECEIVE® PERMIT MIRES 1 YEAR FROM DATE ISSUED �V� 1 !� 1993 (Complete in Triplicate) �1NCOUNTY � E.S Application is hereby made.to San Joaquin County for a permit to construct and/or install the vow t . application is made in compliance with San Joaquin County Ordinance_No. 549 and 1862 and the Rul� � � Joaquin County Public Health Services `P1VIRfl I , Job Address City �� Lot Site/Acreage .F Owner's Name Address Phone Contra' ddre €✓ License Phone TYPE OF WILL/PUMP: NEW WELL ❑ . WELL REPLACEMENT 177 DESTRUCTION ❑ out of Service well Irl 0 PUMP INSTALLATION SYSTEM RUAW OTHER ❑ Monitoring Well ❑ r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 11! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED U5E TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ } C�1� industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing I C9'Oomestic/Private ❑ Gravel Pack C1 Tracy , Type of Casing Specifications Il Public i EI Olher fl Deft-aa* " `Depth of Grout Seal Type of Grout t ....�- I I Irrigation ��Approx. Depth I I aslem Surface 5eai installed by } Repair Work Done dd' Type of Pump H P. State Work Done ❑ Well Diameter Sealing aerial & Depth Well Destruction h Depth :5L.,Filler Material a Depth 1\� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I jDESTRUCTION I I (No septic system permitted it public sewer is I` available within 200 feet.) Installation will$eros: Residence-_. Commercial_ Other _Number'of liting�units: Number 61-.bedrooms Character of solt!�to a depth of 3 feet: Water table depth SEPTIC TANK J1" ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ .• r k Method of Disposal k Distance to nearest:= Well y° Fou d tion ; Property Line 1 ; s LEACHING LINE ❑ No. GLength of lines Tata) length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I .Depths Size Number 'Zo—7 ._- SUMPS LI Distance to nearest: Wall Foundation Property Line =DISPOSACPONDS ' --C] - _ _tom,, ,-• r__ _. �- I hereby certify that I have prepared this.application_and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the San Joaquin County Home owner or licdknsad agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued. I shall not t employ any person in such manner as to become subject to workrrian's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I&hall employ persons subject to workman's compenss- tion laws of California." I Thea applicant must�Ca14 uired in ° , FPI req spdet rte. Complete drawing on r rsa:sida. I " Signed �� _ Title: V��"� . � _ Date: CO FOR DEPARTMENT USE ONLY IApplication Accepted by C41 Date 1 7 Area` l Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant -I Return all copies to: San Joaquin County Public Health Services -T Environmental Health Permit/Services 445 N.San Joaquin, P OL Hoa 2009, Stkn, CA 95201 FEE.` AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. INFO CASH . EH 1121 IREV.1111%) EH t6$ 4 Yy �I r ;