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ow '' APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 4 ;& " (209) 468-3447 MAY i oni �ti7 V (Complete in Triplicate} U� ON�l lel IA,!< HEALTH PERM J Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein de§ iFtie�f Se application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San it Joaquin County,Public Health Services, Job Address 3-3 City Lot Size/Acreage Owner's Name d Addresse` Phone ' Contracta- 1 _Address 4— ��0 License IVa. — Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ " PUMP INSTALLATION SYSTEM REPAIR &---' OTHER D Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE s- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS c INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial Cl Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing omsstic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications Q Public Cl Other ❑ Delta Depth OI Grout Seal Type of Grout t rJ Irrigalion Approx. Depth 0 Eastern ) Surface Seal Installed by .1 Repair Work Done 43 Type of Pump ,14964__ H.P. L 7r _.._ State Work Done [f' Wall Destruction ❑ Well Diameter Sealing Material R Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDIT.ION CI . DESTRUCTION CI INo septic system permitted if public sewer is available within 200 leet.i 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 x 'SEPTIC TANK ❑ Type/Mfg = A ]f Capacity =- No. Compartments PKG. TREATMENT PLT.❑ Method of.Disposal ' Distance to nearest: Well Foundation Property Lines t LEACHING LINE ❑ No. & Lang thFof lines Total length/size- FILTER BED in . Distahcelo nearest; Well Foundation Property. Line SEEPAGE PITS I I 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 j 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 Compania- t* tion laws of California." The applicant must r It required inspections. Complete drawing on reverse side. Signed X Title: a e �. _ _ Date: T =/ F DEPARTMENT USE ONLY S Application Accepted by Date V / Area Pit or Grout Inspection by D is Final Inspection by Data-' Additional Comments. - Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SANFJOAQUIN, P O BOX 2009, STOCKTON, CA 65201 . FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMIT NO. I INF CASH . EH U•Y�IREV.siasr Er+'b26