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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Heal h Bery ees. Job Address10�210City Lot Size/Acreage Ow Ns mess Phone o ration - ✓Z��/�/c! �Ad L e se No. �P! � Po� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN 11 DESTRUCTION ut vice Yell ❑ PUMP INSTALLATION ❑ SYSTEM REPAiROTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .r INTENDED USE- - TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS -- ❑ dustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing mastic/Private ❑ Gravel Pack ElTracy Type of Casing_.. Specifications I'1 Publk Cl Other F1 Delta Depth of Grout Seal Type of rout I I IrriUation _Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.Re,—A State Work D Well Destruction ❑ Well Diameter Sealing'katerial A Depth Depth Filler i6terial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTION I 1 lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Others G Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartment ~ PKG. TREATMENT PLT.❑ Method of Disposal Q> Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size O FILTER BED ❑ Distance to nearest. Well Foundation Property Line 1 SEEPAGE PITS I I Depth Sire Number 4 SUMPS LI Distance to nearest: Well Foundation Propefty Line DISPOSAL PONOS ❑ I hereby certify that 1 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?or which this permit is issued, I shall rorty employ any person in such manner as to become 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 is issued,1 shall employ persons subject to workman's compensa- tion lawn o C nia ' The applic m at c uir inspections. Complete drawing on erre si S' Tit Date: FOR DEPARTMENT USE ONLY �J (,� Application Accepted by * Date i Area F� ` - Pit or Grout Inspection by DateFinal Inspection by NJ Date 4 !a �F Additional Comments: -7 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boa 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CASN K S RECEIVED BY DATE PERMIT-No. . EM 1121[REV.1/R 51 R 4/5- EH 11-96 7,2, s