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APPLICATION FOR PERMIT �ISAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ;1 ENVIRONMENTAL HEALTH DIVISION � P O BOX 2009, STOCKTON, CA 95241 l (209) 468-3447 R (Complete in Triplicate) .i . Application is hereby made to Ssn 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 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. � II' Job Address • it i Lot Site/Acreage R Own is Ns-n dress Phone 1 o '" on a for Ire License No. Phone TYPE OF WELL/PUMP: NEW WEL� 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATIONSYSTEM REPAIR ❑ OTHER O Monitoring WellZ DISTANCE TO NEAREST; SEPTIC TANK 'SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .r estie/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications M Public (I Other I� ❑ Delta Depth of Grout Seal Type of Grout Lf I C3 Irrigalion Approx,DeNh Ea ern Surface Saul Installed by Repair Work Done U Type of Pum '� P, __ State Work Done Y Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEWINSTALLATION 0 REPAIR/ADDITION Ci DESTRUCTION 0 INo septic system permitted if public 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, ❑ �! _ Method of Disposal Distancet`o nearest: f Well' foundation Property Line (,k) LEACHING LINE In No. & Length of lines _ Total length/size r FILTER BED ❑ Distance`to nearest: Well Foundation ��_ _-'--Piop6rty Line SEEPAGE PITS it I Depth IN Sire Number r SUMPS r SLI Distance 6to nearest; Well Foundation Property Line ' z DISPOSAL-.PONDS_ _❑ I hereby certify that I have prepared thi's application and that the work will be done in accordance with. Sa_n Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County t 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 V 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 laws of California." s .. The applicant e) Call fa alt uired.inspe,Ptions. Comp) to drawing on fay9se side. 0 Signed r Title: - -- Date: FOR D116& EPARTMENT USE ONLY t Application Accepted by Date Area / Pit or Grout inspection by i Date Final Inspection by 's `Date Additional Comments: 4 _ 0. Applicant - Return all copies to SAN JOAQ,UIN COUNTY PUBLIC HEALTH SERVICES f '+ 7sJ . 14 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES R " 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE ' AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. INFO '4.20 Q . EH13-241ftEV.I/"$) L� I'll f� /� �r�V EH