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APPLICATION FOR PERMIT SAN 'JOA4UI_X COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 P O BOX-,12009, STOCKTON, CAA 95201 PERMIT RFS 1 YEAR FROM DATE ISSILED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or inatall the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sat= Joaquin County Public Health Services. {� �1 .lob Address Q S()1 2 W IOO CJ�f loy��ity C�h Q Lot Site/Acre e V Cl`C ag Ck Owner's Name Y, rAddress >-� Phone�ij r Contractor s, Address License No. Phone /PUMP: NEW WELL ❑ WELL REPLACEMENT. DESTRUCTION ❑ Out of Service well ❑ TYPE OF WELL PUMP-INSTALLATION 0-• :.......,_ __.SYSTEM-REPAlR-X �- .�tonitori 3► LL - w .___...._._.OTHER.❑ .. �, e31 DISTANCE TO NEAREST:- SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP: LINE FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE i_YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f - ❑Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Puhlic n Other n Delta Depth of Grout Seal Type.of Grout XIrrigation f `.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H-P. State.Work Done Welt Destruction ClWell Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK:. NEW INSTALLATION I ] REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system permitted if public sewer is available within 200 feet.1 Installation ww Serve, Residence— Commercial— Other.- Number ther Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth Cr .SEPTIC TANK. O Type/Mfg .CapacityNo. Compartments PKG. TREATMENT PLT.❑ I Method of Disposal + Distance to nearest. Well Foundatiion Ptopeity Una__L:` r LEACHING.LINEY ❑ No. & Length of lines Total length/size , FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depthrxe Number SUMPS C f Distance to neatest: Well Foundation _ Property Line `' DISPOSAL PONDS; ❑ I hereby certify that:l have preparedthis ap ication and that rules And-reg4tatiOrls of the San Joaquin Cty - fFie work will be done in accordance with San Joaquin county ordinances, state laws, and Home owner or licensed agent's signature certifies the following:-!$4rtify that fn the performance-of-the work for which this permit is issued, I shall nemploy a ot boa r"I the fotlavwnn such Iceerti manner that f Mme su to workman s compensation laws of California."Contractor's hiring or sub contracting signature 9: certify performance of the work for which this permit is issued,I shall employ persons;subject to workman's compensa• I Tian laws�of California.,, i The applicant must sell for all req i "!Cdons. Complete drawing on reverse side. signed Title. Oats.• FOR DEPAFITMENIT USE ONLY p Application Accepted by W r" Date a Area Pit or Grotii Inspection by Date Final Inspection b Additional Comments: JlpQlicant - Retui-n all copies to: San Joaquin Countg Public Health Services,. Bnviroumntal Health Perudt/Services.. x601 S. Hazelton Ave.. P 0 Bou 2009. Stockton, CA 95201 �y x FEE AMOUNT DUE AMOUNT REMITTED _CASH INFO CA5H RECEIVED BY GATE PERMIT NO. EFi 13�I�IREV.i/e 5} i FH 1b7e 45 :9:1;