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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 t pF"IT E%PIRES 7 YEAR ROK--DATE ISUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This t application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address q,355 t r Cif Lot size/Acreage Owner's Name &&kg� Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring well G7 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 f� Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing U Domestic/Private ❑ Gravel Pack ❑.Tracy Type of Casing Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout MI Irrigation —.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done O Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth LIP TYPE OF-SEPTIC WORK:—NEW-INSTALLATION-L.-REPAiR.IADDITION 4--DESTRUCTION. tNo-septic-system-permittad`if-public'sewer it— �tavailable within 204 feet.) Installation will serve: Residence— Commercial Other Number of living units: :Number of'bedroom .r j . �� y b apt Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK, Type/Mfg, Capacity a No.-Compartments -I—T.❑ �'. I Method of Disposal Distance to neap rest Vtilelf G?�'~Foundations Property Linev I LEACHING LINE P. No. b Length of lines Total length/sire r FILTER BED i-1 Distance to nearest: Well �1&49 Foundation �_ Property Line 67 - SEEPAGE PITS 11 Depth t 'Size ` Num bar I SUMPS LI Distance to nearest: 'Well `=_Foundation Property Line DISPOSAL.PONDS O I hereby canity. that I have prepared this application and that the work will be'done'*iiin 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."=Conliactor's hiring of sub-contracting signature certifies the following: "I certify that in the performance of the work.for which this pe'drit is issued, I shall employ persons subject to workman's compensa- tlon laws of C lit ornIs., f __ A The applicant us all f r quired inspections. Complete drawingon reverse side., AV -q�7 E Signed Title: - __ Date: _ -'t✓- r, f_ FOR DEPARTMENT USE ONLYt Applieition Accepted by ) # Data? -- Area Pit or Grout Inspection by Data _FinaE_tri"ction_by_ Date Additional Comments: Applicant - Return all Copies to: 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` W._AMOUNLAEMiIT.ED_ ..-_...AECEIVED.BY -- --DATE --- - -PERMII'NO. - —«--+------- �- . EH13.24{REV.tiASr I�. EM*26 i