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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRE YE FROIs D TE S (Complete in Triplicate) Application is her made-to Ban 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 San + Joaquin County Public �Health services. e/Acreage Z gQ 1y Q� — City`. CL t $iz `/ - �— Job Address Phone Owner's Name e O Address Conttactor_ 'FL CJ�� ' �� Address 7 Al, �E L ��7` License No. Phone��3 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out M Service Well ❑ OTHER ❑ Monitoring well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ❑ DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS r FOUNDATION AGRICULTURE WELL OTHER WELL — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Cl Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation _.._ Specifications ['I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ 11 Public Cl Other I~1 Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. Depth I I Eastern Surface Seal Installed by H P State Work Done _ Repair Work Done U Type of Pump Suing Material y Depth " Well Destruction ❑ Well Diameter Tiller Material & DepthI � Depth _.. TYPE OF SEPTIC WORK: MEW INSTALLATION-R" REPAIR/ADDITION I I DESTRUCTION l l aNailableSeptrwithin 200 feet.)c system ed it public rawer is Installation will serve: Residence Z Commercial— Other BFP/�C Y Number of living units: Number of bedrooms 5,alatD CLAY Water table depth Character of soli to a depth of 3 feet:. le Capacity Z d _,k rNo.,Compartments SEPTIC TANK ❑ Type/Mfg ��, PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well __ZXW _ undation Property Line -- � r l Total length/size i LEACHING LINE LST No. b Length of linea '• � FILTER BED ❑ Distance to nearest: well Foundation � Property Line — t SEEPAGE PITS I�f/Depth Number , SUMPS L1 Distance to nearest, Well /Sd Foundation Property Line" 1E* - _.. DISPOSAL PONDS ❑ y i'" 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, end rules and regulations of the San Joaquin county Home owner or licensed agent's signature certifies the following: 111 certify that in the performance of the work for which this permit is issued, 1 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 i certifies the following:"I certify that in the perlomunce of the work for which this permit is issued, I shall employ persons subject to workman's compansa- tion laws of California.,, i ' I The applicant must call for all ipquired inspections. Complete drawing on reverse side. Signed Title: Date: Z /FOR DEPARTMENT USE ONLY �c�y Date ! Area rApplication Accepted by or Grout Inspection by to /� Final Inspection Data by C r Additional Comments: i Applicant - Return all copies to: San Joaquin Coq Public Health Services Health r Environmental Sealth Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 EE CK RECEIVED BY DATE INFO EE PERMIT NO. FAMOUNT DUE AMOUNT REMITTED H 92 .tilt13 IREv.riK5 EH 14.70