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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRON1lMTAL HEALTH DIVISION 445 N SANJOAQUIN, PHONE (209)468-3420 i t P 0 BOX 2009, STOCKTON, CA 95201 � j: i PERM ITE%PIRES1Y.13 Am, R' FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sea Joaquin County for arpermit to construct and/or install the work herein described. This application is made in compliance with San Joaquin Count`y,Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I � � - C� � Job Address City Lot Size/Acreage Owner's Name _ez r � - ` Address Phone O Contractor Address fid icense No. +�l Phone _ TYPE OF WELIL/PUMP: NEW WELL.'P WELL REPLACEMENT ❑ DESTRUCTIONt of Service 1fe11 ❑ n PUMP INSTALL:ATIOW'D SYSTEM REPAIR L7 OTHER ❑ Monitoring well C] DISTANCE TO NEAREST: SEPTIC TANK \A t SEWER LINES DISPOSAL FLD. PROP. LINE � FOUNDATIOfV AGRICULTURE WELL OTHEfl WELL PITS/SUMPS INTENDED USE TYPE OF WELL' kOBLEM AREA �' CONSTRUCTION SPECIFICATIONS I_! Industrial ❑ Operi Bottom ❑ Manteca Dia. of Wall Excavation Oia. of Well Casing .�. «..�..-.. .---- +_�Y_ , _'-w'...,=S - - _ y_.- .._.... C1 Dorrlestia/Privite ❑ Gravel Pack ❑ Tricy Type of Casing- "` - 9 '"-- 'Specifieafions"` V) Public 1-1 Other rl Delta Depth of Grout Seal Type of Grout I i Irrigation. _Approx.-Depth.,, I,1 Eastarn-`: µ\ Surface Seal Installed by `� �`� _ Repair Work Done U Type of Pump �H.P St a Work Dane tt 1 -Sea11 4 Material.i. s r` W eN Destructions.-��Weli piamater - ng Depth ' •�� , r Depth JrS $ >Miller�Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION l I (No septic stem p y permitted if public sewer is f� available within 200 teal.) 14 Installation will serve: F!"dence Commercial Other E Number of living units: .Number of bedrooms Character of soil to a depth of 3 fear. 'I Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT.O- R Method of Disposal - Distance to nearest: Well Foundation Property Line LEACHING LINE '�Cl No. b Length of lines it � Total length/.airs - FILTER BED Grp... Distance to nearest: Well 1 Foundation Property Lina SEEPAGE PITS-` 11 Depthi E Size ill Number � SUMPS . LI Distance to nearest: Well i� Foundation- DISPOSAL PONDS ❑ i ! Property Line r I hereby certify that 1 have prepared this application and that the work will be done in,accordance with San Joaquin county ordinances, stats laws, and rubs and regulations of the San Joaquin County " r, * � _ •^"" � Home owner or'licansed agent's signature osrtifies the following; "l certify that in the performance bf the work for 4ich this permit-is llssued, I shall not employ any parson 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 fhs work for which tKis permit is issued, t shall employ persons subject to workman's compensa- tion laws of California." The applicant t requi red ' Completedrawing on.lever *id 9. Signed X -— p .Date: Z,'I F r R DEPARTMENT USE ONLY �f Application Accepted by ` x Dots Z-4 � Area LG 1� Pit or Grout Impaction by Final Inspection by Data Additional Comments:: . Applicant - Return all copiejllto:111 %.IlJoaquin 'County Publi'c`}Health Services _--;--- --Environmental,Health.Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 ii FEE AMOUNT bUE [E7T REMITTED K RECEIVED BY DATE PERMIT�NO. INFO (� I CLASH . EH 13.24{NE1f.t/x61 ►r{V r ®V �o