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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, .PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT-MIRES 1 YEAR FROM DATE ISSUED (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 cestpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. fir- cA /yy Job Address _ � l/%- 1� - -- City rr�� Lot Size/Acreage ZJ /V 241z" Owner's Name SAddress `�' � • ' `"`� Phone ` `— Q� T Contractor Address 0 /27 5�e_ o --/__ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ 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 ` 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \�Vl 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications V 1'1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by \ Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is �/ available within 200 feet.) Installation will serve: R° 'dente Y Commercial _ cher Number of living uniu: _ L Number of 4tdrooms Character of soil to s depth of 3 feel Water table depth SEPTIC TANK. Type/Mfg 111, Capacity No. Compartments PKG. TREATMENT PLT,❑ ` //��- Method of Disposal fiL Distance to nearest: Well � Foundation y _A6 Property Line j LEACHING LINE K No. & Length of lines � �_ Total.length/size FILTER BED ❑ Distance to nearest: Well Foundation —_� � Property Line SEEPAGE PITS Depth Size k Z' Nu tuber_ SUMPS Lt Distance to nearest: Well �� Foundation 6 Property Line_d DISPOSAL PONDS ❑ 1 f 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, Ind", rules and regulations of the Sen Joaquin County " Home owner or Ikensod 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 workmen'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,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must csll for aft required inspections. Complete drawing on reverse side. Signed Title: Date: i R DEPARTMENT USE ONLY Application Accepted by Q� ��JW�O1iw'1 Date 2— Area ® � Pit or Grout Ins 1 pattion by Date Find Inspection b Date Additional Comments: f Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 4 • 4455K N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERM177NO. • EH 17.21 tnEV.1iN4! EH 11.21 >W 1'