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APPLICATION FOR PERMIT i ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 140 -1 r r -1 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 + i, P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRESY FR M DATE SUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This j application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San { Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name ddress 4Phone ZJ (r Contractor Address License No. Phone TYPE OF WELL/P MP: NEW WELL 0 WELL REPLACEMENT .. DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION'' -AGRICULTURE WELL OTHER WELL PITS/SUMPS l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic lPrivate ❑ Gravel Peck ,❑ Tracy f Type of Casing Specifications .'t f'1 Public fl Other Cl Delta r Depth of Grout Seal Type of Grout dQ : I•I Irrigation ;Approx..Dapth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump. _H.P; State Work Done — Well Destruction O Well Diameter` Sailing Material i Depth Depth driller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION Iff REPAIR/ADDITION i I DESTRUCTION l I (No septic system permilted if public sewer is I _ = available within 200 feet.1 Installation will serve: Residence_L_ Commercial_ Other . ,. E t Number of living units: � Number of bedrooms ..-�......��. Character of soil to a depth of 3 feet: -Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity -0 d No. Compartments PKG. TREATMENT PLT. ❑ p id {,� Method of Disposal Distance to nearest: Well/�' 6 Foundation Property Line LEACHING LINE ❑ No. & Length of lines g .Total length/size \ FILTER BED ❑ Distance to nearest: Well � jL_Q Foundation _�!Q Property Line _!c=— 7 r SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well/ --- Foundation I j2 4 Pro�erty Line - !6 d 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, and rules and regulations of the San Joaquin County _' Home owner or licensed agent's signature certifies the following: "I certify that in Mie performance of the 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 eerlifies the 1`0140wing: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California," k The appl!cent"at call for all reqyM inspections. Co lete drawing on reverse side. Signed Title: Date: a F R DEPARTMENT USE ONLY Application Accepted by DeteArea Pit or Grout Inspection by 61 Date nanepection by Date Additional Comments: !F Applicant - Return all copies. to: San Joaquin County Public Health Services Environmental Health Permit/Services H 445 N San Joaquin, P O Box 2o09, Stkn, CA 95201 _FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + INFO CASH Ily , ©o • EM12-II[NEV.I/sal C? El!11.2E �