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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �`� ' ENVIRONMENTAL HEALTH DIVISION ` P 0 BOX 2009, STOC%TON, CA 95201 i (209) 468-844rL3`l� Lk�7 �• PERMIT UPIRES 1 YEAR PROM DATE ISSUED_ (Complete in Triplicate) i Application is hereby made,to San 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 1662 and the Rules and Regulations of San Joaquin County JPublic Health{-Services. A ob Address '1 1� City ti 1 IP 5 (4Lot Size/Acreage {{ t/ l 'P Owner's NameA `—Q—Address 1 5 ! r'� 0�� hone ��a$-75 7�1`� / oMraUor_©Wnl ��` Address License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well Li PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 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 11 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications M Public f:7 Other ❑ Delta Depth of Grout Seal Type of Grout Ml Irrigation _.Approx..Depth ❑ Eastern Surface Said Installed by Repair Work Done D Type of Pump H.P. State Work Done_ Well Destruction D Well Diameter Sealing Material Z Depth Depth Piller Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION CT DESTRUCTION fNo septic system permitted if public sewer is vailable within 200 feet.? 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.Cl Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE El No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation _ Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS CI 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, t shall employ persons subject to workman's compensa- tion laws of California." he applicant st call for all require inspattions. Complete drawing on reverse side. igned Tide: _ DIA) 6 Date: r~ ` OR DEPARTMENT USE ONLY Application Accepted by Csdru4 Dateea Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments.- Applicant omments;Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT RE-MITTED CASH RECEIVED BY DATE PEAMIT NO. E1]•7�INEV,1/MS) I .b� 25 EFSH11.2a I