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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447PERMIT EXURES 1 YEAR PROM DATE lould) ,' '. Y' (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. 544 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. 1 f Job Address i - r� �`e �^ City YeI4A CiLot Site/Acreage Owner's Name lrt/k 0 /L d r4 WI i�1 Address __�C�I IM it � _ •. ._ Phone Contractor u du1e� Address fQ SW � l �l� C�` � License No. �1 Phone TYPE OF WELL/PUMP: NEW WELL C] WELL REPLACEMENT n DESTRUCTION ❑.Out of Service Well ❑ PUMP INSTALLATION,K SYSTEM REPAIR C7 OTHER ❑ Monitoring Well [7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION t AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial © Open Bottom 0 Manteca Oia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public I'l Other C) Delta Depth of Grout Seal Type of Grout CI Irrioation Approx, De th 0 Easternuriaca 5eul Installed by Repair Work Done 0 Type of Pump _ H,P. State Work Done _ Watt Destruction ❑ Well Diameter $•! Sealing terlal i Depth Depth 1�0 Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/AODITION 0 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet,) Installation wile serve: Residence^_, Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. C') Method of Disposal Distance to nearest: Welt Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Wolf Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I sha€I employ persons subject to workman's compensa- tion laws of California." The applicant call for all re ired 'nspeCtions. Complete drawing on reverse side. / 'f Signed Title: _ ` nj'J,��,�� T - r}••.C'L=+41�G��..._ Date: �,�,•••- FOR DEPARTMENT USE ONLY ` Application Accepted by _-4,jt, Date ++�3 A a IS Pit or Grout Inspection by Date Final Inspection by Date q'30 Additional Comments: / Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t T ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE€NFO AMOUNT DUE AMOUNT REMdTTED CASH RECE€VE0 a DATE PERMIT NO.