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APPLICATION FOR PERMIT - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PAYMENT P 0 BOX 2009, STOCKTON, CA 95201 RECEIVED (209) 468;'3447 tg iP. SEP 18 r/�11 R kR9A PATE ISS (Complete in Triplicate) SANT _10AQUIN C-OUNTY PUBLIC HEALTH SER'/iGES Application is hereby maade,to San Joaquin County for a permit to construct and/.or install the �?' e i 'Td e¢ s>�it rf�i Ke l application is made in cmwilance with San Joaquin County Ordinance No. 549 and 1862 and the Itujes and 'iiegu tione of San Joaquin County Public Health Services. I .p Job Address Ep ,City Lot Size/Acreage Owner's Name Address 1.4 __ Phone I i 'Contract' —'� �+ Addres�� iynse Nd Pitons TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT C-'} / DESTRUCTION o Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR {GY OTHER ❑ Monitoring Well L� 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 C7 Ind ei ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing omeatie/Private ❑ Groyel Pack ❑ Tracy Type of„Casing Specifications ❑ Public I:1 Other ❑ Delta Depth of Grout Seal Type of Grout A}W CI Irrigation —..Approx. Depth ❑ Eastern _ ' urlace Seal,installed by Repair Work Done ape of Pump H,P. �'�� Ej' , State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth - Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR lADDIT ION.!DESTRUCTION G (No septic system permitted if public sewer is available within 200 leet.l r Installation will serve: Residence --Commercial Number of living units: - Number of bedrooms — Character of soil to a depth of 3 teat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ _ r Method of Disposal x Distance to nearest: Well Foundation. Property Line r LEACHING LINE ❑ No. & Length of lines b Total length/size 4. FILTER BED n Distance to nearest: Well Foundation Property Lina r I SEEPAGE PITS 11 Depth Size } Number s SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that It a 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 signatuie`eeriifies 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, 1 shall employ persons subject to workman's compensa- tion Iowa of California." If ► The applicant required insfAip ns. Complete drawing on rev t►side. Signed Title: Date: FOR DEPARTMENT USE ONLY p Application Accepted by - h11f Date r �� Area Pit or Grout Inspection by Date 1 Fir,,sl Inspection by J]dte O L 9Z R , Additional Comments: Applice.nt — 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 EEEAMOUNT DUE AMpUNT REMITTED CK I RECEIVED BY DATE PERMIT'NO. INFO CASH,, . EKt: 1331(REV.hits) y�r1 TV 07)— k — 0 3(S4 6:0 `ZC Z y4:�2^322/ K:�•xe