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�F. .. APPLICATION FOR PERMIT ` .f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES• ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 i P 0 BOX 2009, STOCKTON, CA 95201 PERMIT SPIRES 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 Saw Joaquin County Ordinance No. 549 and 1862 a.od the Rules and Regulations of San Joaquin County Public Health Services. Job Address Io 73 1 r ,_ City Lot Size/Acreage Owner's Name Address ' S• Phone ntractor A Address `T" `� License No. Phone -Z /--_Wt TY F WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT'Llti DESTRUCTION Out of Service Yell PUMP INSTALLATION D SYSTEM REPAIR ❑ f OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.— PROP. LINE -- - FOUNDATION AGRICULTURE WELL _ OTHER WELL f f' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS'. -' 0 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing- KDonnesticlPrivate 0 Gravel Pack ❑ Tracy T Type of Casing_ i1 Specifications €'1 Public [-I Other Il Delta _Depth of Grout Seal r'2 r Type of Grout Ot Irrigation —Approx. Depth I ),Eastern Surface Seat Installed by Repair Work Done U Type of Pump- H..P: State Work Done - r- Wall Destruction p 'Wets Oinnisitai° ' . St artg 11113terial f1 Depth r Depth - Tiller tlaterial i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION t I lNe septic system permitted if public sewer is available within 200 loot.) VVViii777 Installation will serve: Residence— Comrmercial' .Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well.. Foundation ' Property Line LEACHING LINE rl No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Propefty•Line SEEPAGE PITS It Depth y Stag Number SUMPS El Distance to nearest: Well'' Foundation Property Line DISPOSAL PONDS Q I hereby certify that 1 have prepared this application and that the will be done in accordance with San Joaquin county ordinances, state laws, and rubs and rogulatione 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."Contrictoes hiring or sub-contracting signature cartifies the foNowing:"I certify that in the performance of rhe work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion larva of Caliifmn)a." -' The applicant must call for all required Inspect' a. Complete'drawing on reverse side. -- - C3- x _3 Signed Title: - Date: - - Ofi DEPARTMENT USE ONLY. Applicetlon Accepted by Dots Area A ;�A,�Z-lcl lS _ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 0 o H^ Q'i S a ee � Applicant - Return all copies to: San Joaquin County public Health Services' 49A( 01- 10 rel`--y.. `� Environmental Health Permit/Servicesdr fyv`f ry r/ /J 445 N San Joaquin.-P-0 Box 2009, Stkn, CA 95201FEE AC%�4tir 7 RGu�on[cur�i 1NF0AMOUNT DUE AMOUNt REMITTED CASH RECEIVED aY PATE PERMIT'N0. . EM 11~26)REVWo 0'E-2G��m� - 3��#•53 93- EH 1{-'a