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APPLICATION FOR PERMIT SAN ','TOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONI[MTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 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 Vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City .tsC Lot Size/Acreage t Owner's Name _ t� t= S Address Phone 17 Contractor Address + License No.,2j?!/��a+ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION ❑ Out of Service Yell ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 Monitoring hell ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack 0 Tracy type of Casing_ Specifications ['I Public 1-1 other F1 Delta Depth of Grout Seat Type of Grout I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I t lNo septic system permitted if public sewer is available within 200 feet.) (� Installation will serve: Residence JL�- Commercial��Other Number of living units: Number of bedrooms ��J Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Typo/Mfg L opacity 2cl;'o _ No. Compartments PKG. TREATMENT PLT. ❑ C M Method of Disposal Distance to nearest: If — Foundation��Property Line —ML-14:-7— LEACHING LINE No. 8 Length of lines _ ff� � T Total length/size F� FILTER BED ❑ Distance to nearest: Well Foundation — Property Line -21'S"�T7 SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to rlsarest: well Foundation Property Lina DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin County Home owner or Ncensed 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 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 laws of California." The applicant must call for squ in ns. Complete drawing on reverse side. r� g Signed X Title: - Date: FOR PART T USE ONLY Application Accepted by Date �J res Pit or Grout Inspection by Date Final Inspection b Dat Additional Comments: S c ~ 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 FEE INFO AMOUNT DUE AMOUNT REMITTED / K RECEIVED&V {DATES PERMIT'NO. dk.• EM 147e t11EV.iiMSr •/� // / �Q Q x SD �� SSB i O 0