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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 408-3447 2MUIT EXPIRES I YEAR PROX DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application Is trade in compliance with San Joaquin County Ordinance No. 5and 1862 and the Rules atsd Regulations of San Joaquin County Public Health Sery ces. Job Address ,City Lot Size/Acreage 9I= d Owner's Na Address �_ Phone ` Con clot License No. Phone f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM T n DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATI0� SYSTEM REPA OTHER O Monitoring'Well C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS L FLD, PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1.1 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing t:7estic/Private 0 Gravel Pack n Tracy Type of Casing Specifications i l Q Public �! Other ❑ Delta , Depth of Grout Seal Type of Grout 0 Irrigation j-Approx. Oe th ` ❑ of 4 Surface Seal Installed by Repair Work Done �Typa of Pump Y x �_ State Work Done & --�T:t-__a Sealing Material i Depth Well Destruction XO Well Diameter Depth`° r�-y "'Fi'iler ldaterir►1 iTDepth^^' - � TYPE OF SEPTIC WORK; NEW INSTALLATION D REPAIR/ADDITION-Ll..,DESTRUCTION CJ INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: -Residence Commercial— Other l Number of living units: Number of bedrooms r t f Character of soil to a depth of 3 feet: Water table depth k SEPTIC TANK. ❑ Type/Mfg Capacity s No. Compartments PKG. TREATMENT PLT. 0 + + Method of Disposal Distance to nearest:; Well Foundation Properly Line LEACHING LINE 0 No. & Length-of lines Total length/size FILTER BED i-1 Distance to nearest: Wall Foundation Property Line t SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to near6i'V. Well Foundation Property Line DISPOSAL PONDS ❑ _ _ ., - �,r... -. 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 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 workmen'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 toworkman's compensa- tion -California.' ..--•—-.�„^-w^ ^- ----- - - f The applicant st tail for II required inspections. Complete drawing on re rse 'side.-} ; p Signed Titl Date:!:� F DEPARTMENT USE ONLY Application Accepted by Date r Pit or Grout Inspection by Data Final lilapection by Date 7/ Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES - 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 13.74INEV.I/A5)