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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM 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 made in coWliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address P, Cityaf1ki Lot Size/Acreage ner's Name Address —�� n Phone \ I n ,PDW� J):&PAd 1 ense No. Phon y TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrials 13-open Bottam.____,❑_Manteca Dia. of Well Excavation Dia. of Well Casing 4 . stic/Private ❑ Grev l Pack 0 Tracy Type of Casing_ Y Specifications r s� f"l Public Ll Other' Cl Delta Depth of Grout Seal Type of Grout I i Irrigation _Approx. Dsp l I astern !� Surface Seal Installed by r� Repair Work Done U Ty�a'of.P.ump H.P.- _ ,--,_ State Work Dona u G Well Destruction D Well`Diarneter Seali""rig Material-ill; Depth Depth Filler Material a Depth i" TYPE OF SEPTIC WORK:. 'NEW INSTALLATION I ) REPAIR/ADDfTION i I DESTRUCTION l I ilio septic system permitted if public sewer is -� available Within 200 feet.) a Installation will serve: Residence— Commercial_____ Other Number of living uniti: Number of bedrooms Character of soil to a depth of 3.1eat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity N6.-Compartments PKG. TREATMENT PLT. Cl i j "" Method of Disposal ,y Distance to nearest: Well Foundation Property Line �II LEACHING LINE :,t t`i Cl No, 5 Length of linea t Notal length size FILTER BED ❑; Di to nearest: Well- —Foundation-- - Property Line SEEPAGE PITS - 1 1 _Dep h f Size Number SUMPS LI Distarlgr to-r r�st:__WelI_Foundation-- , Property Line DISPOSAL PONDSZt `• ,❑ I hereby certify that I have prepared this applicA and that the work will be done in g"cco�rdsnce 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 rnanner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following:"I"n at in the pprtormancs of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif }The applicant s ull for ail inspections. Complete drawing on r;.:erA�side, WXY t S Title: Date: FOR DEPARTMENT USE ONLY t Application Accepted by ��f.-_ k�,, -- V 1_ s Date _`"1�- ' Z- Area 0_Z-_` ` Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: j Applicant - .Return all copies to: San Joaquin County Public Health Services I Environmental Health Permit/Services 1 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEFVED BY DATE PERMIT'N0. EH 144a 6,0