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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STWKTON, `CA 95201 �I]Q/ � (209) 468-3447 S�4r1� ! 3 19 Y R ,,IS3U �p rC y�CQL �J CO$N� (Complete in Triplicate) �� r�(IYA� '7VIC S f Dr�r�f &cpplication Sa hereby made to San Joaquin County for a permit to construct and/or install the work herein descri ed. This application Is made in compliance with San Joaquin County Ordinance No. 549 end 1862 and the Rules and Regulations of San 1 Joaquin County Public Health Services. Job Address i' City t Size/Acreage w f Owner's Name Address _ � -- Phone Contras Addre —dense N Phont . TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Ll PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well 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' [I 1riPstria! ❑ Open Bottom � O Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private ❑ Gravel Pack r ❑ Tracy , Type of Casing Specifications M Public l-1 Other ❑ Delta. Depth of Grout Seal Type of Grout - CA Irrigation m Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done W Type of Pump 6411� H.P. - State Work Done 1J Welt Destruction ❑ Welt Diameter sealing Material Z Depth 0 [ Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW"INSTALLATION 0 REPAIRIADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living unite: Numbenof bedrooms Character of &oil to a depth of 3 fest: Water table depth ( . SEPTIC TANK ❑ T ype/Mfg Capacity No. Compartments D PKG. TREATMENT PLT. Ci Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE Cl No. ii Length-of-lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Si:e Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby canity 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 sut5ji3ct to workman's cpmpeniafion 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 imploy persons subject to workman's compensa- tion laws of California." The applicant ra Or omptete drawing ori r90 se side, Signed X Title: - Date: FOR DEPARTMENT USE ONLY Application Acceptedby Date �1 h�' Area t Pit or Grout Inspection by Date Final Inspection by a-- Data Additional Comments: Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 448 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 INFO O AMOUNT DUE AMOUNT REMl70 C11 RECEIVED BY GATE PEA417'N0. EH 13-24IREv.Iin5l Ile— Ls-,&+V 4/s—0Z) 32iaO — FMr 146