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APPLICATION' FOA PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N..SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES l YEAR FROM DATE .ISSRED (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 made in compliance with San Joaquin County Ordinance No. 549 and 1562 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name r Address �d. Phone A33 -:21PY Contractor ddress Spea Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private . ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications .n I1 Public fl Other f"1 Delta Depth of Grout Seal Type of Grout I i Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by -V Repair Work Done 0 Type of Pump H.P. Sta Work Do Well Destruction Well Diameter ( Sealing Material i Depth =A4 ! Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is { available within 200 feet.l Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of kA to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/W9 Capacity No. Compartments y PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line k LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line „r 9e SEEPAGE PITS 11 Depth Size Number; I SUMPS Ll 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 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 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 compenss- tion laws of California." The applican c or all requir ins ns. Complete drawing on r rse side Signed X Title: Date: OR DEPARTMENT USE ONLY i Application Accepted by Date le q3 Area I� Pit or Grout Int pectlon by . Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 �O AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE IFEE NTPERMITNO. a EH 13-24 IRI:V.t N S 1 Wb 6 U. p EH 14.30 .