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APPLICATION FOR PERMIT 4 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 Health Service Job Address 73 L n[� 4L e City Lot Size/Acreage Owner's Name Address--�� / Phone J� w Owner's y Address `f" License No. Phone - t TY F WELL/PUMP: - NEW WELL ❑ WELL REPLACEMENT'❑ DESTRUCTION V Out of Service Well PUMP INSTALLATION O SYSTEM REPAIR ❑ ' OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL T PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS` 0,Industrial O Open Bottom O Manteca Dia. of Well Excavation T Dia. of Well Casing P)(Domestic/Private O Gravel Pack O Tracy Type of Casing-- �(l Specifications I'1 Public Cl Other n Delta Depth of Grout Seat s Type of Grout 1}Irrigation _.Approx. Depth I IyEastern � Surface Seal Installed by v Repair Work Done U Type of Pump H Pry State Work Done_ Well Destruction ❑ Well Diameter 3eahinj; Material s Depth Depth Filler Material i Depth 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 1' available within 200 feet.) VAP 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. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal Distance to nearest: Well -Foundation Property Line j LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS I'I Depth Size Number j SUMPS Ll Distance to nearest: Well'' Foundation Property Line ` DISPOSAL PONDS O I hereby certify that I 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 cenifies the following: "I certify that in the performance of the work for which this permit is issued, 1 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 California." -The applicant must call for all required insPect' s. Complete drawing on reverse side. Signed NL4 , � '1!A/ '� Title: ;A`��V1(�i�.- Date: 3 FOR DEPARTMENT USE ONLY `f Application Accep �Tted by Date Area_ f�3�si��.le�lls *fwo� Pit or Grout Inspection byDate Final Inspection byDate Additional Comments: 1�! 0 D h" o co/ 1 '0 O IApplicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services j 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 ��/ aC' �FEE e F INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE l PE((RpM1T NOG{. • EH 13- IREV.1/851 t.•M1a wo �e�� (,pc�xCa-i� 3-9- i3 ?3 EH