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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 d" = i4.�/ (Complete in Triplicate) I Application is hereby made to sari Joa_qu<in 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. Job Address -5 Cit r � y Size/Acreage Owner's Name —_C� Address Phone I /• Contrattor Address License No. Phone TYPE OF WELL/PUMP: KEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAItV OTHER ❑ Monitoring Well [7 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 n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout 0 Irrigation Approx.'Depth ❑ Eastern Surface Seal Installed by Repair Work Done .0 Type of Pump. H.P. State Work Done Well Destruction ❑ Well Diameter' Sealing Material i Depth �l Depth' Filler Material i Depth 1692&L /W_ TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Cl DESTRUCTION CI fNo septic system permitted if ptrblic sewer is available within 200 feet.) Installation will serve: Residence—1 Commercial— Other , Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth R SEPTIC TANK. ❑ Type/Mfg � Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance t nearest: Well Foundation Property Line i i j LEACHING LINE ❑ No. & Lon gth of Eines Total length/size FILTER BED n Distance to,nearest; Welt Foundation Property Line I � 4 SEEPAGE PITS 11 Depth Sire Number BLIMPS LI 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, ands rules and regulations of the San Joaquin County Home owner or licensed agent's signature 1canifies 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 bBcoms subject to workman's compensation taws 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, 1 shall employ persons subject to workman's compensa- tion laws of California." i The applicant r ued i omplete drawing on reverse ia Signed le: — Date: r IF T USE ONL I r IApplication Accepted by 446 r Date Zr -[ Area Pit or Grout inspection by Date Final Inspection by,inn, pate Additional Comments: i 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 95201 FEE AMOUNT DUE ' AMO U REMITTED CK RECEIVED BY INFO CASH DATE PERMIT'NO. j I • EFIt�24 IREV.,iH6) ry�7 � l�' l� � ��L IL-7 r rJ� V-.i