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APPLICATION FOR PERMIT 25 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 Nb PERMIT EXPIRES 1 YEAR PRO DATE 100M as S, (Complete in Triplicate) Application is hereby tttade,to San Joaquin County for a permit to construct and/or install the work herein described. This application Is Stade in cotitpliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health' ervices rVA ob Address ! City 5� 0r-l<Zet!f Lot Size/Acreage ��ffffff wner's Name '� Address Phone g ' a ntractor^_�1.�A9� Address License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service We11 ❑ PUMP INSTALLATION C7 SYSTEM REPAIR ❑ OTHER 0 Monitoring Well U I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Li Industrial ❑ Open Bottom ❑ Manteca L=Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack .n Tracy Type of Casing Specifications M Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout M Irrigation _,Approx. Depth C7 Eastern Surface Seal Installed by Repair Work Done v Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth. TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION Cl DESTRUCTION I (No septic system permitted if public sewer is available within 200 fest.1 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 _ t Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. $ Length of lines Total length/size FILTER BED C-1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS O 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 of sub-contracting signature certifies the following: "t certify that in the performance of the work for which this permit is issued, f shall employ persons subject to workman's compenza• tion laws of California." XSIapplicant must call for all required inspections, Complete drawing on reverse side. s ^ q�ed Title: .__ Date: [ a FORfARTMENT USE-ONLY Application Accepted by Date Area I Pit or Grout Inspection by Data Final Inspection by _.__ Datel 7 ' Additional Comments,- Applicant omments:Applicant - Return all copiers to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 FEEi INFO AMOUNT DUE MOUNT REMITTED CASH CK 11 RkEiVED BY DATErr�� /LPERMIT'NO. . EH 13'24 IREv,I/n51 n� A� ,--a-f `7 —00 EH it•� [ L