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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 Y t. (Complete in Triplicate) f Application is hereby made to San Joaquin Count for a tyconstruct application ie made in einotail, vork ompliance with San Joaquin County OrdinanceNo. 5498ando1862 and theeRules andherein Sans Joaquin County Public Health Services. c Job Address City / ! ! Lot Size/Acreage Owner Nome d1dress - %— / �J Phone Contractor Address License No. Phone— i TYPE OF WELL/PUMP: NEW WELL ❑ ` WELL REPLACEMENT ❑ DESTRUCTION ❑ Out et Service Well ❑ t PUMP INSTALLATION ❑ SYSTEM REPAIR Cl' OTHER ❑ Monitoring Well_ L7 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 U Domestic/P►ivate ❑ Gravel Pack ❑ Tracy yType of Casing Specifications _ C Public (-I Other C-) DeltaDepth of Grout Seal - ' F Type of Grout CI Irrigation Approx, De th ❑ Eastern -•^^ - --- Rte. -» ; p Surface Seal Installed by Repair Work Done U Type of Pumpa J H.P. ' State Work Done ` Well Destruction ❑ Well Diameter Sealing Material.i Depth s Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION-❑ ;REPAIR/AUDITION 0 DESTRUC7l0 .r .No septic system permi=-, c available within 200 feetI Installation will serve: Residence Commercial. - Other -- --�--..a,,.� �.• . ..,ys _ ___ i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: y i ASEPTIC TANK Water table depth:Type/Mfg Capacity. No. Compartments I PKG. TREATMENT PLT, C) Method of Disposal Distance ld nearest: Well Foundation� Property Line _.,__•__._,._ r (y r �,;. LEACHING LINE ❑ No. 8 Length of lines FILTER BEDTotal length/size [ Distance to nearest: Welly Foundation r ! } Property Line � ► SEEPAGE PITSt i I Depth Size Number ! SUMPS Cl Distance to nearest: Wellk Foundation �______^ Property Line DISPOSAL PONDS ❑ ' V t I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and rules and regulations of the San Joaquin County Horne owner or li'Cerised 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 subiect 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." The appftcant $I call for all required inspections. Complete drawing on reverse sf Signed f, Title, -V j` # Date: '� ,• FOR DEPARTMENT USE�ONLY Application Accepted by /I z�_'90 '-. ,Date �_.Area Pit or Grout Inspection by Date --� Final Inspection by Data Q Additional Comments: % A ' Applicant - Return all copies to: Q 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 AMOUNT REMITTED .. INFO 'I ASH RECEIVED BY DATE PERMIT'NO. • EH 13.241REV, 77'v� —7y �n � f fj /�, EN 14.26 I (L'V KU• 47 :.,