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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOS 2009 1 STOCg� A 95201 (209) 468— y R (Complete in Triplicate) I E ! Application is hereby toads to San Joaquin County for a permit to construct and/or install the Work herein deacribed. s in County Ordinance No. 549 and 1862 and the Rules application is made in co>gpllance with San Joaqusad Regulations of San € Joaquin County Public Health Services, p f ®( City Lot Size/Acreage 'M f Job Address i � i`. � ►Cc�l.r- Phone ry Address � ' � �-- e i Owner's Name ' X �efcs�_AddressLicense No. Y7 Phone '3 Contractor 'NEW — DESTRUCTION -1 Out ofi�ServiCe Nell Cl TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN ❑ Monitoring Well p SYSTEM REPAIR 0 OTHER ❑ IM PUP INSTALLATION C] k DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES ._ �� i AGRICULTURE WELL OTHER WELL PITS/SUMPS FOUNDATION _._�� I. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D'ia. of Well Excavation Dia. of Well Casing f_l industrial ❑ Open Bottom © Manteca Specifications• ] r U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Depth of Grout Seal Type of Grout ❑ Delta t M Public I'll Other _ u 1 { Surface Saul Installed by M Irrigation �M.Approx, Depth ❑ Eastern IM t State Work Done Rapsir Work Done U Type of Pump H.P. I Sealing Material & Depth � k Well Destruction ❑ Wd�l Diameter Filler Material i Depth �' Depth TYPE Of SEPTIC WORK: REPAIR/ADDITION 0 DESTRUCTION LI INcllseeptic syste��pfr iltedlil public sewer is NEW INSTALLATIONbWe r I �� c �� sell Installation will serve: Residence �. Commercial Z Cather � a Number of living units: A Number of bedrooms I� Character of soil to a deptof3 feet. water table depth (f I No. Compartments SEPTIC TANK. ❑ Type/Mfg Capacity ' PKC, TREATMENT PLT.Cl Method of Disposal Distance to nearest: Well Foundation Property Line ip i� LEACHING LINE 11 No. & Length of lines Total length/size ,r FILTER BED n I Distance to nearest: Well Foundation Property Line l SEEPAGE PITS t 19 Depth Size Number IM N ' SUMPS CI Distance to nearest: Well foundation Property Line �--� ,f i , 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 f 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 shell 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 rhe work for which this permit is issued, I shall employ persons subject IO workman's compensa tion laws of California." II; III The applicant must call for all required inspections. Complete drawing on rexerse side. 11, li (y Date: 2-' L�'ql I Signed Title: y �I R DEPARTMENT E ONLY jl Date Area Application Accepted by II ect °�j�� - Pit or Grout Inspection by pate Final Inspion b Datait "L Additional Comments: a? W Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES y 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE CK RECEIVED By DATE PERMIT'NO, INFO AMOUNT DUE AMOUNT REMit tE0 CASH . EH t17411SEV,ItK5i f �� R Laz.� m EH 14.1e I