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APPLICATION FOR PERU SAN JOAQUIN-COUNTY PUBLIC HEAL HICES ENVIRONMENTAL HEALTH DIV S1W 445 N SAN JOAQUIN, PHONE (20 ) 20 �} , / P O BOX 2009, STOCKTON, C of V PERMIT EXPIRES 1 YEAR FR 1[ D AL --7/6 (Complete in Triplica efNY # 0� � Application is hereby made;to San Joaquin County for a permit to construct an jor 90110 ' application is made in compliance with San J.osquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Job Address Q r °4 e City Lot Size/Acreage t ' —S Phone Owner's Name i ZAddress A icense Mo Phone `' Contractor/ r 0 Address �� - �TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR F OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINT: FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L1 Industrial * ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I') Public fl Other . . i'1 Delta Depth of Grout Seal Type of Grout I I Irritation .. Approx. Depth I I Eastern Surf a Soul Installed by Repair Work Done ,�` Type of PumpH.P. Stats Work Done {; Well Destruction , ❑ Well Diameter Sealing Material L Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms Character of sod 10 a depth of 3 feet: Water table depth SEPTIC TANK ❑ Typa/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Ci Method of Disposal Distance to nearest: Well Foundation Property Line _s f LEACHING LINE L1 No. A Length of lines Total lengthtsize FILTER BED ❑ Distance to nearest: Well Foundation ...-,r- Property Line SEEPAGE PITS I I Depth Size Number SUMPS - Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O r '% ` . . -_ -_ F . I 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 workmen's compensation-16vs df Cilifornia." Contractor's hiring of subcontracting signature certifies the follows " certify that in the performance-of ths'Work for which_this'permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of C nia.' ,I ,4 The app)' nt must 11 for all required 'r tions mplete drawing on r er side. I Signed Title: Date: '3 FOR DEPARTMENT USE ONLY rr Application Accepted by ` Date Z. Area 1 Pit or Grout Inspection by Date Final Inspection by Data I g 5 Additional Comments: k Applicant - Return all"copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O 90x-2009, Stkn, CA 95201 3 IFEE NFO Ac/M-�ODUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EIS 13.24111& iesl 6 J. /✓ /� / � �� tfN 1�•7a