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APPLICATION FOR PERMIT ' - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION y 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 I PERM IT_EXP I RES 1. YEAR FROM DATE ISSUED (Complete in Triplicate) J1i Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This mI application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Publics Health Services. f �V+ C- Job Address e/� r � fir City Lot Rize/Acreage Owner's Name Address / / &A A&W-46-" Phone Contractor / Address icense Na. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT . DESTRUCTION ❑ Out of Service Well ❑ j PUMP INSTALLATION O SYSTEM REPAIR' OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L] Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications i'1 Public f-1 Other Fl Delta Depth of Grout Seal Type of Grout t�!Irrigaliort _.Approx. Depth l I astern Surface Seal Installed by '1Re4pair Work Done ❑ Type of Pump H.P. �5tate Work Dona ��'rf Well Destruction . ❑ Well Diameter Sealing Material & Depth Depth biller Material & Depth TYPE of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth !f} SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ � Method of Disposal n.l Distance to nearest: Well Foundation Property Line_t r . r LEACHING LINE C1 . No. & Length of lines Total length/size r I O FILTER BED ❑ Distance to nearest: Well Foundation Property Line .a_ b -SEEPAGE PITS [ I , Depth -Size Number SUMPS + LI Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS 0 - 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 CZi rules and 4gula'liohs 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 shall not employ any person in such manner ss:to,become subject to workman's compensation laws of California." Contractor's kiting 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 persons subject to workman's compensa- tion laws of California." The applicant u' ns.'Complete drawing on rev rillLside. Sig ned 'title: Date: l FOR DEPARTMENT USE O LY Application Accepted by �AsDate Area O ` "�•`"` Pit or(trout Inspection by D`ja�ta• Final Inspection by Date Additional Comments: �'r�_ / Applicant - Return all copies to: San Joaquin County Public Health Services $gvironmental Health Permit/Services > 445 N San Jokquin' , P O Box 2009, $tkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED' ' CASH CK 9 RECEIVED BY DATE PERMIT'NO. ♦ EH 1410 • - f