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Y a. APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 f1Tni/TIT F•%PIRES 1 YEAR Ij`ROM DATE ISSUEQ V_ (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 Publ Hes, h Services. � City Lot size/Acreage Job Address �- r v no Owner's Nam ddress Contra or �� dessr ,L� * L c ns No. Phone TYPE OF WELL/PUMP: NEW W O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O PUMP INSTALL.ATI SYSTEM REPAIR O OTHER O Monitoring Well [I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing C.] Industrial O Open Bottom O Manteca Dia. of Well Excavation Type of Casing Specifications �-�B mastic/Private O Gravel Pack D Tracy Type of Grout - O Publie I:1 Other O Delta Depth of Grout Seal G Irrioation __.Approx. Oept C E�slern /`S}+rfaco Seal Installed by _ Repair Work Done U Type of Pum ��'f H.P. State o Sealing Material i Depth Well Destruction O Well Diameter ?` biller Material 4 Depth Depth F SEPTIC WORK: NEW INSTALL TYPE OATION 0 REPAIR/ADDITION L'I DESTRUCTION CI allo seperwThin 200 retitled if public sewer is (^ Installation will serve: Residence— Commercial Other CyQ Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 toot: SEPTIC TANK- O Type/Mfg Capacity No. Compartments Method of Disposal PKG. TREATMENT PLT, O Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. A Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Size — Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby certify that 1 have prepared this appfication 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, 1 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 applican must call r requiree�d iinss�pections. Complete drawing on rave side. Sign d P(Ji L Title: Date: FOR DEPARTMENT USE O&�- 4— Date / q �V/� Area Application Accepted by i Pit or Grout Inspection by Date Final Inspection by tYl/ Date 11 Additional Comments: Applicant - Return all copies to: ENVIJOAQUIN RONMENTALCOUNTY PUBLIC HEALTH HEALTHDIVISIONPERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 � - FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. CASH INFO /\� 4 4 4 . EH 13.24 IREV,i i R 51 Y. - „W! wl ` ` ' 1 EH*2!