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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES N� ENVIRONMENTAL HEALTH DIVISION P O BOX 2009 STOCKTON CA 95201 (209) 468-3447 YEAR ?M PATH 15SUE2 �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 aid Regulations of San i J�uiinn�County Public Health Services. S Job Addr a' �ty _. City r r Lot Size-/Acreage --I,, Owner's Name s C '4 r D� J � - Address M-� Phone Contractor Address ` License No. ---Phone r1`w TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTI • ' t of Service Well L-1PUMP INSTALLATION ❑ SYSTEM REPAIR 0 pT Monitoring well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS vV * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications M Pubtic Cl Other C} Delta Depth of Grout Seal Type of Grout 0 Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done D Type of Pump H.P. State Work Done _ Well Destruction D Well Diameter Sealing Material i Depth Depth Piller Material i Depth ' TYPE OF SEPTIC WORK: W INSTALLATION 0 AEPAIRJADDITiON 0 DESTRUC septic system permitted it public sewer is / x ailable within 200 feet.) Installation will serve: Residence^ Commerciat_ Other Number of living units, Number of bedrooms Character of toil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity--- No, Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. $ Length of lines Total length/size FILTER BED [_1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ s 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 d — " — ' I 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." Contractors 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 w' �' Y Pe p p y persons subject to workman's compenss- tion laws of California." The applicant st ail for all r uired ' pections. Complete drawing on reverse side, Signed Title: Date: FOR DEPARTMENT USE ONLY f Application Accepted by Date 1 j �.Area s � f Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments: Applicant Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES _� ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ell, 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 I I IEEENFO AMOUNT DILE AMOUNT REMITTED CK f CASH RECEIVED BY DATE PERMIT'NO. • EN 13-24 IREY.1/n Sl