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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ! ENVIRONMENTAL HEALTH DIVISION p 0 BOX 2009, STOCKTON, CA 95201 �T (209) 468-8t`177' / N ATE X&M R IN (Complete ill Triplicate) i Application is hereby medI to San Joaquin County for a permit to construct and/or install the work herein described. This a. application is made in compliance with San Joaquin County Ordinance No 54 apd,1662s� the Ru� and Regulations Banal Joaquin County Pub c Heh Se ices. �u(^I d^! i r CityLot Size/Acreage Job Address ddrtiss ' Phone owner's Name e No. hone Contract r SS sT l TYPE OF LL/PUMP! �� NEW WEL © WELL REPLACEMENT ❑ DESTRUCTION 0 Out of S vice Nell Gl PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ Mon toring Well C7 DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _._____—n— PITS/SUMPS I FOUNDATION AGRICULTURE WELL OTHER WELL a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing n Industrial ❑ Open Bottom © Manteca D;a. of Well Excavation Specifications U Domestic/Private 0 Gravel Pack C7 Tracy Type of Casing ID Public i"1 Other ❑ Delta Depth of Grout Seal Type of Grout GI Irnoation IApprox. Depth ❑ Eastern Surface Seal Installed by ' Repair Work Done U Type of Pump H,P. Stats Work Done Sealing Material L Depth Well Destruction O Welt Diameter - Deal, Piller Material i Depth 15 TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAIRIADDiTION L,--DESTRUCTION F-I afvailabPerw thin 2f festc system "led i! public sewer is Installation will serve: Residence_L Commercial— Other ^ Number of living units: Number of bedrooms —4;1— r Character of coil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ f Type/Mfg Capacity No. Compartrrianti . F PKG, TREATMENT PLT. C1 / Method of Disposal 'Distance to nearest: Well Property Line k LEACHING LINE Cl 1I�No. & Length pf.lines Total {ength/sizeY.. KILTER BED n ii Distance to nearest: Well a ion 11,2Property Line — - r I EEPAGE PITS I I Depth -Size____oat Number SUMPS LI '.'Distance to nearest; WellP;aAl undatian _ Property Lina DISPOSAL PONDS ❑ I 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 ageni's 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 ofsub-contracting signature F certifies the following: "t cartit�y 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 muq call for r uir ins ti s. C mplete g on reyprse side. / Signed tee. Date: R DEPARTMENT USE ONLY Application Accepted by , 1 Ij — _ Date " Area I� pate .y al `t! Pit or Grout Inspection by Date Final inspection by Additional Comments: Applicant - Returc all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r ` A.RNVIRONMENTAL>HEALTH DIVISION PERMIT/SERVICES II .445 N SAN JOAQUIN, P 0 BOR 2009, STOCKTON, CA 85201 FEE AMOUNT DUE AMOUNT REMITTED CASH pECEEVE4 BY DATE pEFIMIT N0. `} �I . ENU-74tM1EV.1/MSI INFO {73 00 �"�� { cll— EH:1•�6 `I k Ir