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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 REMIT EXPIRES YEAR FROM DATE IHSUM - (Complete in Triplicate) Application is hereby made to Sao Joaquin County for a permit to construct and/or install the work herein described. This application is made in cmzWlience with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address I &I C/f Al �A2 1d �� City Lot Size/Acreage Owner'o Name a Address s e- Phone Contraclor S!1, _ ,1_—Address License No. 3 Phone p TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR � OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WILL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f_l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Y U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications A ublic Cl Other ❑ Delta Depth of Grout Seal ps of Grout Irrigation Approx, Depth �C] Eastern Surface Seal Installed by ` O Repair Work Done 0 Type of Pump Y41H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION J❑ REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted if pubiie sewer is available within 200 feet.) installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines --- Total length/size -' FILTER BED ❑ Distance to nearest: Well Foundation Property Line i I SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance.to nearest: Well Foundation Property Line 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 end regulations of the San Joaquin County Home owner or licensed agent's signature cemifies 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 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 law"of Gelifor The applicant call foil re it d in ctions, Complete drawing on reverse side, Signed Title: IL Date: _,� "" ZS`- FORD PARTMENT USE ONLY 2 Application Accepted by Dab�y ^� r Area / Pit or Grout Inspection by Date Final Inspection Date Additional Comments; — Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES k ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES S 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 i FEE AMOUNT pUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. )FEE t �1 � CAS' r� J ♦ EH 13.241REV.1/ASI L,t J.U� fi -7�f .� �'di--r�l~L �.'•��q-.,. EH,axe 11 "'[ �X�