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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL REALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468--3447 "1 RIMIX WIRES I YEAR rROM DATA ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application In made-in coatpliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of Ban Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's m Address one Contractor dress License No. Phone TYPE OF WELL/P P: \NEP WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service well ❑ PUMP iN5 LATION C1SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS { 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r U Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications M Public C7 Other ❑ Delta Depth of Grout Seal Type of Gout 0 Irrigation Approx. Depth I❑ Eastern Surface Saul Installed by Repair Work Done D Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter sealing Material i Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIRIADDITION M DESTRUCTION 9FMo septic system permitted if public sewer is available within 200 feet.) W Installation will serve: Residence — Commercial-_._r Other Number of living unite: Number of bedrooms Character of soil to a depth of 3 feel: Water table depth " SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl � Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby canify 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 agents 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 California The applicant m f Il re mage, ions. Complete drawing on reverse side. 9 r Signed Title: -- Date:Iv Ff �. �,f„ R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection b ._ Date Additional Comments; 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 85201 � Y; kFEE AMOUNT DUE AMOUNT REMITTED �A8H RECEIVED BY DATE �PIERM17 NO. 1i