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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468--3447 EMIT ESQ I„YEAR FROM DATELSSUSD (Complete in Triplicate) Application is hereby leads to San Joaquin County for a permit to construct and/or install the worts herein described. This application Is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. l Job Address �, 1� Yt f"J �LYLGi ell C City _5Z`�7 11� Lot Size/Acreage Owner's Name .,am' A/ItK — Address Address So.$*%e- Phone Contractor�_R"1 AddressEQk,590 S S7``K / 7.5 Q5; License No, 30 Phone S 9 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [7 DESTRUCTION ❑ Out of Service Well Gl PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 f-7 Industrial ❑ Open Bottom ❑ Maniac@ Dia. of Well Excavation Dia. of Well Casing t X.Domestic I Priva to Q Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public i-1 Other D Delta Depth of Grout Seal Type of Grout \ CI Irrigation Approx. De thEastern Surface Seal Installed by Repair Work Done U Type of Pump H.P,3 State Work Dona 3 Well Destruction D Wall Diameter r' Sealing Material i Depth Depth _^00 Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION L_J REPAIRIADDITION M DESTRUCTION Cl (No septic system permitted if public sewer is available within 200 feet-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 Capacity -No. Compartments PKG, TREATMENT PLT. ❑ fi Method of Disposal Distance to nearest: Well "Fo ndation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED n Distance io nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 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;-l-shalt•impioy persons subject to workman's compensa- tion laws of California." The applican st call for all uir inspgctions, Complete drawing on reverse side. i 7 Signed Title: Date: •/ `� FOR DEPARTMENT USE ONLY Application Accepted by Data A� 01-0 Area Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERYIdES ` ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE i INFO MOUNT DUE AMOUNT REMITTED CASH AECEIVEp BY DATE PERMIT'NO. CH. EH 14:m IREV.I/h 61 Oft F �r ©�l 7 J +� d ,