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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION r 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i ERMIT EXPIRES 1 YEAR FROM DATE S (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This y application is made in contgliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. .lob Address City Lot Size/Acreage 46=&�— Owner's Name Address C� -75;24hone 7Z.7 Conlraclor- Address G License No. ��Phone TYPE OF WELL/PUMP: NEW WELL ❑ VdLL REPLACEMENT P DESTRUCTION ❑ out of Service Well ❑ _PUMP INSTALLATION ❑- SYSTEM REPAIR OTHER ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION. AGRICULTU RE_WELLLL - ' _OTHER WELL-_?ITS/SLIMES ; r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 77 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 1'1 Public I"1 Other F1 Delta Depth of Grout Seal Type of Grout llfIirvigafion ____Approx. Depth I I Eastern Surface Seal Installed by �1 Repair Work Done U Type of Pump .rrvrH.P. State Work Done A,4t�T rssrsrts>,� Well Destruction ❑ Well Diameter a Sealing Material i Depth _ BA Depth i 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 leet.l v L s Installation will some: Residence-A Commercial__^ Other Number of living units: Number of bedrooms y� Character of soil to a dWh of 3 feet: Water table depth Ji SEPTIC TANK ❑ Type/Mfg Capacity No. Comt� , PKG:TREATMENT PLT. ❑ ""' Method '~" -� f Distance to nearest: "Well Foundation Property1992 Line b: i LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED © Distance to nearest: Well Foundation Pro rt+e� - ,T IRVICES IINVIRONMENT SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line ` DISPOSAC-PONDS` •_C] 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 canifies 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 OF 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." . I The applicant must call for all required inspections. Complete drawing on reverse side. 1' Signed X Title: Date: 3 IT FO DEPARTMENT USE ONLY _ Date Araa Application Accepted by .: - - r I Pit or Grout Inspection by Data Final Inspection by fflVLK - Date 'f Additional Comments: ' Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services i� 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 k {{INFO ��FEE AMOUNT DUE I AMOUNT REMITTED t CASH RECEIVED BY DATE PERM17'N0. ' EH 13.24(REV.f)R5!