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APPLICATION FOR PERMIT � r 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 YEkR FROM DATE Ua= (Complete in Triplicate) truct and Application is hereby made to Baa Joaquin County for a permit to cons549and Regulations of San application is made in compliance frith Ban Joaquin County Ordinance No. 5k9 andd herein described. This 1 1install the and the Rules Joaquin County Public Health Services. . �� t �'� �¢� _ City Lot Size/Acreage Job Address r - ® r /J / Q Phone Owner's Name f�'�ref Address ^ e` r OA9 I . ZM /�+ License No.- �T- Phone Z j a Contractor ddress TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out Mon serviceWell Well n PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL FLD. PROP.,LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Open Bottom ClManteca Dia. of Well Excavation Dia. of Well Casing C7 In tris! ❑ Ops Specifications. Domestic/Private ❑ GravelPackL� Tracy Type of Casing_ I'i`Public 1-1 Other n Delta depth of Grout Seal Type of,Grout I I Irrigation _.Approx. Dep I Eastern +�Surface Seal Installed by Repair Work Done L] Type of Pump H.P. ` lam- State Work Done Sealing Material A Depth We11 Destruction O Well Diameter Tiller Material i Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I'I"REPAIR/ADDITION I I DESTRUCTION I I available tic.within 200 teetpermi�led�t public rower is Installation willserve: Residence— Commercial_ Other _ .r Number of living units: Number of bedrooms sY �.. Q Water table depth Character of$oil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disptisai —n Distance to nearest: Well Foundation Property Line �) LEACHING LINE 0 No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina !� 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 rubs and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies 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 cenifies 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 laws of California.,, The applican :ust k �s tions. Complete drawing on reverse side. all re42 Signed X �C —._ Title: {I�DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspet tion by Data/ Additional Comments.- Applicant omments:Applicant - Return all- copies to: San Joaquin County Public Health Services 4 Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK a FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By BATE PERMIT'N0. INFO . EH tl24IREV.I/A51 ��.� � t9�L 5g0b 8Z a3 q3-1D EH 14.1m.