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R APPLICATION FOR PERMIT P � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICTS C'el ENVIRONMENTAL HEALTH DIVISION NCV P O BOX 2009, STOCKTON, CA. 95201 SA,ry 16 1992 P(�0�/C�` QU/N co r (209) 468-3447 ENVIR p HEAL r (NrY PEMIT EMIIRE@t@ i,>aATri lic ATE ISSUED NMENrA�HEA t��l��S (Cop A pal Application ie 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address G _ City Lot Site/Acreage Owner's Name Address Phone Contract License TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well L PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well 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 CONSTRUCT_ION SPECIFICATIONS n_ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 94 Ci omestic/Private Gravel Pack C1 Tracy Type of Casing Specifications 6 ❑ Public Cl Other l3 Delta Depth of Grout Seal Type of Grout CI Irritation —..ApproK. Depth---Cl Eastern Surface Seal installed by Repair Work Done .0 Type of Pump - f2 - H.P. - State Work Done 7 Wall Destruction 0 Well Dila tmster ' mm =Sealing Material i Depth Depth { Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION CI DESTRUCTION CI Mo septic system permitted if public sewer is Iavailable within 200 feet:) Installation will serve: Residence Commercial Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments I PKG. TREATMENT PLT.❑ r Method of Disposal -r Distance to nearest: Well Foundation Property Line _ i LEACHING LINE Cl No. & Length of lines. LTotal length/size i FILTER BED 1=1 Distance to nearest: Well 'Foundation Property Line SEEPAGE PITS Il Depth Site j Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 P 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 I 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 calJor all requir inspections, Complete drawing on rse sins. a Signed Title: Date: r i FOR DEPARTMENT USE ONLY I Application Accepted by Date I` y 0 Area i Pit or Grout Inspection by Date Final inspection by Date Additional Comments: - Applicant - Return all copies to., SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOR 2009, STOCKTON, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED C RECEIVED 8Y DATE PERMIT'NO. r EH 13.24 TREY,s/KSI IGvaj EN 448