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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERX1T 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 CountyPublicHealth Services. Job Address J r Lit, 1_`:_1rv2JTF_J_ RIJ City --9— z/UY Lot Size/Acreage I hereby cenity 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 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 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 la." ksThe opplic t mustall ro wired ins ctions. Complete drawing on reverse side. ignedTitlo:/ Ui �-- Date: FO DEPARTMENT USE ONLY ` �j Application Accepted by (I L Data \`_ I C� i Area 0 Pit or Grout Inspection by Date Final Inspection by / Date /T— Additional Comments: AIL=JY�/l `;c"l'fL� '�` r: /,�'.� ,;L��LJzFlO �t,� h Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 EH 13 b/ IREV. I/ It 5) EH :/.26 FEE NFO AMOUNT DUE AMOUNT REMITTED SASH wner'a Name` /%� !� �T f f /L� Address Phone PERMIT NO. Contractor _Ck11tN/al qc Address _ License No. _ Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACE NT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM EPAIR ❑ OTHER ❑ Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION A ICULTURE LL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AR NS1"RUCTION SPECIFICATIONS Cl Industrial ❑Open Bottom ❑Manteca a. 01 Well Excavation Dia. of Well Casing U Domestic/ Private ❑ Gravel Pack ❑ Tracy Typ f Casing Specifications ❑ Public 1-1 Other ❑ Delta Depth o rout Seal Type of Grout CI Irrigation Approx. Depth ❑East Suriace Seal Called by Repair Work Done U Type of Pump H.P. State Work Done _ Wall Destruction ❑ Well Diameter Sealing Material Z Depth Depth _ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION Cl DESTRUCTION (No septic system permitted if public sewer is variable within 200 feet.) 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines _ Total longth/size FILTER BED E.1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenity 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 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 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 la." ksThe opplic t mustall ro wired ins ctions. Complete drawing on reverse side. ignedTitlo:/ Ui �-- Date: FO DEPARTMENT USE ONLY ` �j Application Accepted by (I L Data \`_ I C� i Area 0 Pit or Grout Inspection by Date Final Inspection by / Date /T— Additional Comments: AIL=JY�/l `;c"l'fL� '�` r: /,�'.� ,;L��LJzFlO �t,� h Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 EH 13 b/ IREV. I/ It 5) EH :/.26 FEE NFO AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT NO.