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b APPLICATION FOR PERMIT r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O SOX 2009, STOCKTON, CA 95201 (209) 468-3447 ,,pMI T ERP-I_PM_ 1- YEAR FRQX .PATE IS5UED (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Put,tic Health Services. L 'r} e�— Job Address .cg, 114 " t _. City of Size/Acreage Owner's Name _ Address -.� -- _—_ Phone _ Canlractors-L-�� h�_Addre r �- icenseN Phon ` TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell L'1 PUMP INSTALLATION O SYSTEM REPAIR 91" OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1.1 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing �U Do stic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications �YPubiic 1:1 Other ❑ Delta Depth of Grout Seat Type of Grout G Irrigation �/ Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done �7 Type of Pump, H.P..3 State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI INo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Pffl ,� Character of soil to a depth of 3 feet. Water t SEPTIC TANK ❑ Typo/Mfg Capacity No. ComIVED1 PKG. TREATMENT PLT. Cl MethocK 1992 Distance to nearest: Well Foundation Property f, C01M,,ITY —- - - - R 11_1H_i SF- LEACHING LINE Ll No. & Length of lines ^. Total IengthVJ4W � 1� ZI _ p , FILTER BED f=1 Distance to nearest: Well Foundation Property Line V� SEEPAGE PITS 11 Depth Size Number SUMPS 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, 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 subcontracting 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." The applicant mus III al required i tions, Complete drawing oaverse :ids. _— r Signed Title: 2 r - Date � FOR DEPARTMENT USE ONLY �%Application Accepted by Date Area d;� Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 05201 INFO AMOUNTDUEAMOUNT REMITTED CA RECEIVED BY DATE PERM17 NO. . EN 13•NL�Q — EN',426 �)