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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOC%TON, CA 95201. (209) 468-3447 PEMIT EMIRES I YEAR FM PATE ISSUED (Complete in Triplicate) Application is hereby me4e,to San Joaquin County for a permit to construct and/or install the work herein described. This application. Is made in cmipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County public Health Services. r 1 Job Address �t � Gity Lot Size/Acreage �V Owner's Name ddress Phone Contracto Address License NoZ2 Phone l_PP l TYPE OF WELL PUMP. NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well Cl PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 Monitoring Well El 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 Cl Industrial O Open Bottom G Manteca Dia. of Well Excavation Dia. of Weil Casing U Domestic/Private . 0 Gravel Pack E3 Tracy Type of Casing Specifications M Public t.l Other © Delta Depth of Grout Seal Type of Grout M Irrioaiion w.Approx. Depth ❑ Eastern " ".",Surface Sea! Installed by Repair Work Done U Type of Pump. H.P. State Work Done V' Well Destruction O Well Diameter Sealing Material A Depth �►�" Depth Filler Materna A.Depth TYPE OF SEPTIC WORK; ,NEWINSTALLATION 4V REPAIRlADDITION Cl DESTRUCTION i✓I (No septic system permitted if public sewer is I "r'� ' available within 200 lost,I Installation will serve: Residence.[__. 'Commercial Other Number of living units: __L1_ Number of bedrooms _ l i ,gig Character of soil to a depth of 3 feet: ' Water table depth E SEPTIC TANK D Typ.lMfg { CapacityVNa. Compartments PKG. TREATMENT PLT. C ( Method of Di" to nearest: Well �- )Roundation Property Line ddy ; LEACHING LINE U No. 8 Length of lines Total length/size FILTER BED C1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth -Si", Number SUMPS Ll Distance to nearest: Well z_ Foundation ' Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work wilt 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 of sub-contracting signatur certifies the following; "I certify that in the performance of the work for which this permit is issued. I shall employ persons subject t_o workman's compensa- tion laws of California." The applicant ust call for requir ctions, Comple a drawing an reverse side. r Signed Title: Dater F R PARTMENT USE ONLY G Application Accepted by Date / 9 Area or Grout Inspection by Fina! Inspection by Additional Comments: it Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES e 445 N SAN JOAQUIN, P 0 Box 2009, STOCKTON, CA 95201FEE E I INFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERM17 NO. I I EH 13.24 IltEv,r,M s, EH t,•2e 1� .d LG-0?—yc. c� i