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APPLICATION 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 Services. i�� /" Job Address _„� -� w �l"kj '�-�_,_� City_5^C� Lot Size/Acreage 60 Owner's Name �71� Address _ I Phone Contractor_ _l i Address License No. Phone TYPE OF WELL/PUMP: NEW LL ❑ WELL REPLACEMENT n DE UCTION D Out of Service Well ❑ PUMP INSTALLATIO SYSTEM REPAIR D OTHER C Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DI SAL FLD. PROP. LINE FOUNDATION A ICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AR CO RUCTION SPECIFICATIONS I7 Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation Dia. of Well Casing C] Domestic/Private ❑ Gravel Pack ❑ Trac Type ype acing_ Specifications I'1 Public (-I Other n Delta Depth of Gro Seal Type of Grout I I Irrigation _ Approx. Depth I stern Surface Seal insta by Repair Work Done LJ Type of Pump H.P. ate Work Doyle , Well Destruction O Well Dianne Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW i STALLATION I 1 REPAIRIADDITION I I DESTRUCTION (No septic system permitted if public sewer is qq/� available within 200 feel:► Installation will serve: Residence x Commercial_ Other Number of living units: _-5— Number of bedrooms (� Character of soil to a depth of 3 feet: Water table depth P SEPTIC TANK © Type/Mfg Capacity No. Compartments PKG. TREATMENT PET. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire _ Number SUMPS Lt Distance to nearest: Well foundation Property Line 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 laws, an 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 no) 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 Iifornla." The appli ust call for II re fired inspec 'ons. Complete drawing on reverse side. Signed �' Title: 6U� ;ZG Date: FOR DEPARTMENT USE ONLY Application Accepted by Date b Area Pit or Grout Inspection by Date Final Inspection by / 5 —A�v- Date Additional Comments: r"lad C� l�s c �e : Applicant - Return all copies to: San Joaquin County Public Health Services is !" � /� Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOU.NfT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. EH 13.21 fNEV.rKs EH 11-20 t l r7 l o r