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f APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 XM FROM DATE S (Complete in Triplicate) Application is hereby made.to Ban Joaquin County for a permit to construct and/or install the cork herein described. This application is made in compliance frith San Joaquin County Ordinance No. 549 and 1852 and the Rules and Regulations of San Joaquin County Public Health Services. ob Address City ' Lot Size/Acreage 111111 P XO wner's Na Address Phone ,?, Contractor Address x License No. Phone TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER ❑ Monitoring Well O 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing 11 Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing_ Specifications 1 Il Public Cl Other n Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. Depth I I Eastern Surface Seel Installed by Q Repair Work Done. -❑ Type of Pump H.P. State Work Done Well Destruction ❑ Wall Diameter Sealing Material i Depth Depth Filler Material i Depth �r YPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feat,} 1�f� Installation will seen: Residence 4 Commercial- Other i Number of living units-. Number of rooms -1� /2� Character of soll to a depth of 3 feet: Water table depth 1 SEPTIC TANK. t- Type/Mfg vtr Capacity A4 No. Compartments PKG. TREATMENT PLT. Ll l Method t?f Di sal Distance to nearest: Well 100 Foundation 3 0 Property Line LEACHING LINE f No. 6 Length of lin s` Total length/size 2-0 FILTER BED CI Distance to nearest: Well t7O Foundation - tf 0 Property Lina SEEPAGE PITS It}� pth �S Size 3 Number SUMPS Distance to nearest: Well youndi tiwt, f' Property Line S DISPOSAL PONDS ❑ E t✓ 1 hereby certify that I have prepared this application and that the work will be done in accordance with'aan Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the fallowing: "I cartify that in the performance of the work for which this permit is issued, I shall not employ any parson 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." The applicant t call for all ed ins coons. Complete drawing on r/77Z v side. v �+�- Date: �--- .� ? L— /{Signed � Title: ZFOR DEPARTMENT USE ONLY Ap ice n Acyted by Date r 2- Area D Pit r Grout InspaKtron by Data Final Inspection by Date . dditb.01 Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 H San Joaquin, P O Box 2009, Stkn, CA -95201 FEE AMOUNT DUE MOUNT REMITTED SH RECEIVED BY DAT PERMIT'NO. INFO �} 4� . EN I�IItttEY.l/rl51 l / rD I` � moi( � EN 14.20 1� l L V I