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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 to (209) 468-3447 PERMIT EXPIRES 1 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. Job Address City�� Size/Acreage r Owner's N AddressPhone Contr ct ttlCie"ss License No.l Phone p TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTIO t of Service Well ❑ PUMP INSTALLATION O SYSTEM REP IR ❑ OTHEK❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. "tom'"_ PROP. LINE—'W—+ FOUNDATION AGRICULTURE WELL -12` OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications * Public ('1 Other O Delta Depth of Grout Seal Type of Grout CJ Irrigation Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done a0 Type of Pump .H.P._ State Work Done_ Well Destruction t K Well Diameter sling Material & Depth �� ,/n, N" Depth a� F ler Material & Depth f t �f TY-elJ l' 1' TYPE OF SEPTIC WORK: NEW INST TION0 IR/ADDITION 0 DESTRUCTION CI (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other , P Number of living units: Number of bedrooms 4 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line (� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 m all to all required inspections. Complete drawing on reverse side. Signed Title:` i/-� �� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date - Area ^� Pit or Grout Inspection by Date Final Inspection byeYL �' ? 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 CK IEEENFJ AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 1344IREV.ri951 T EH;62s