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r w4 APPLICATION FOR PERMIT �� r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION � . . -x 445 N SAN JOAQUIN, PHONE (209)468,.-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I Y FROM DATE ISSUPP (Complete in Triplicate) 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 costpliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San i Joaquin County Public Health Services. 1__�J'ob Address City S t o r k t_n-►Z-CIkt 81ze/Acreage Owner's Name Address Phone - y Contractor Address 5icense No.F 9 f17 r�i fl Phone 93 6 631 -4-155 7YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well 0 Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER �4 Q of ihni Cal orin s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ Ci Industrial ❑ Open Bottom E) Manteca Die. of Well Excavation ` "DIS:of Well Casing C7 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ ` Specifications FI Publicf 1 Other Delta Depth of Grout Seal . Q Type of Grout S I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth pi;h-SO11 CUtt i ngS Depth hiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is available 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 j SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments D PKG. TREATMENT PLT.0 µMethod of Disposal Distance to nearest: Wel Foundation .Property Lina - LEACHING LINE ❑ No. a Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number (, SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ , I hereby certify that 1 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 in : "I certify that in the performance of the work for which this permit is issued, 1 shah not certifies the follow pe Homs owner or licensed agent's signature ce g Y 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." I The applica mus call for all required ' s ns. Complete drawing on reverse side. S� Title: C S-7 Date: t - 3o_C) FO DEPARTMENT USE ONLY Application Accepted by Dais Area Pit or Grout Inspection by Date Final Inspection by Data LZ-- Additional Comments: l S 5 [ U na Applicant - Return all copies to: San Joaquin County Public Health Services Irm- Environmental Health Permit/Services I `- ypb C) 6 Oc„.-k. 445 N San Joaquin, P O Box 2009, Stkn, CA 9N201 FEE AMOUNT DIE AMOUNT REMITTED CASH RECEW By ' ATE PERMIT NO. f: INFO i OVEK M24(REV �&, EH 14-M ff ,