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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES p ENVIRONIMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE. (209)45203420 P)? P O BOX 2009, STOCKTON, CA Sq R 2 3 �® � �N�oq 1993 PERM�T (Complete in TriplI YEAR icate) ISSUED-DATE lRa/VpkNE, Q L p&S�R�TY Application in hereby reads to San Joaquin countyfor a to mitito construct and/or and Instal62 and the Rules work hand erein Beac at Regulations appliestion is made in compliance with San JoaquinY �N Joaquin County Public Health Services. a Cit Lot Size/Acreage Job Address Phone Address Owner's Name A Contractor Address License No. Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 57 of Service Aell ❑ � TYPE OF WEL /PUMP M OTHER ❑ onitoring Well C7 PUMP INSTALLATION ❑ SYSTEM REPAIR 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 W Dia. of Well Casing L) Industrial : .. ❑ Open Bottom ❑ Manteca_Y Dia. LWe11_Excavation ' Type of Casing Specifications Domestic/Private ❑ Gravel Pack Cl Tracy Type of Grout Fl Other # F1 Delta Depth of Grout Seal {� I'l Public , y 3 I i IrflUation Approx. Depth I I Eastern Surface Seal installed by _ State Wo k Done $. Repair Work Done Type of Pumps •� - Sealing Material nth - 4 Well Destruction ❑ Well Diameter hiller Material A Depth Depth LJ TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR IADDITION i I DESTRUCTION I I avail bps wi thin system permitted if public sewer is 6 Ts Installation will serve: Residence Commercial.....� Other Number of living units. Number of bedrooms Water table depth Character of soil to a depth of 3 feet: J Capacity- _ No• Compartments SEPTIC TANK. ❑ Type/Mfg o1 f]ispossl_ PKG. TREATMENT PLT. ❑ . _ Distance to nearest: Well Foundation Properly Line LEACHING LINE ❑ No. 6 Length of lines Totai length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS II Depth ? Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line F DISPOSAL PONDS .❑ w rk will be done in accordance with San Joaquin county ordinances, state laws,and I hereby certify that 1 have prepared this application and that the wo j rubs and regulations of the Sen Joaquin County "!certify that in the performance of the work for which this permit is issued, I shall not Horne owner or licensed agent's signature certifies the following: f 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 the work for which this permit is issued,I shall employ persons subject to workman's compansa tion bws of California." a The applicant st call for 1 required inspeptions. Complete drawing on r erse ids. c i' Signed Title: "''1'`f _ Data: 1 F DEPA Data � a Application Accepted b Pit or Grout Impaction by Date Fina! Inspection by Date a f Additional Comments.- Applicant omments:Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 WFEE AMOUNT.DUE AMOUNT REMITTED RECEIVED BY DATE PERM17'NO. . Eu 13.24 iREV.1/0;41 k+Q'~' y c0® r� �� / /8-0 EH