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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 PERMIT EXPIRES i 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services._ 1/4vat�t�—�Z,.,,(/41? va/�j' /Job Address Ale,le �� G`v� S� ales `14y City` ' ' Lot Size/Acreage \ •r. Owner's Named a Address Phone Contractor_4 `O Address (0 w I/ /,clao( laLicense No. Phone 30 2— f� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Ll PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 i f_l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Specifications M Public CI Other O Delta Depth of Grout Seal Type of Grout M Irrigation _.Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth •1X' Depth Filler Material i Depth C- TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION CI DESTRUCTION I (No septic system permitted it public sewer is available within 200 feet.) Installation will 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 O Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT,O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED 1-I Distance to nearest: Well 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant mu for required ' ps tions. Complete drawing on re erre side. .( Signsd X �IA7 M, Tide / Date: OR DEPARTMENT USE ONLY �7 Application Accepted by Date /2 2 G q Area G �� Pit or Grout Inspection by Date Final Inspection by,.,J` 4 Date Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT NO. . EH21IREV.iinsl �-1q CH-4i�•2e 1