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f APPLICATION FOR PERMIT , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 YEAR (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 amde in ccuPllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of San Joaquin County Public Health Services. /_ a Job Address ' t �"® Q City_ S K � Lot Size/Acreage j QCY,( �' Owner's Name Address. t Phone 1- 6t Z r— I Contractor — Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTIONA Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHEIT ON Monitoring Well L7 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 F1 industrial ❑ Open Bottom 0 Manteca Dis. of Well Excavation Dia. of Well Casing U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing 'Specifications. o A Public C.1-^�Ojher ❑ Delta Depth of Grout Seal Type of Grout !~' i CJ Irrigation t(Ls..Approx. Depth © Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. PStats Work.Done-_ k• ; Wait Destruction © Weil Diameter Sealing Material i Depth Depth Piller Material & Depth TYPE OF SEPTIC WORK: EW'INSTALLATiON 0 REPAIRlADDiTION M DESTRUCTION Cl (No septic system "tted if public sewer is available it Iest.1 Installation will serve: Residence_ ommercial Other ¢ Number of living units: Number of be s - Character of 6011 to a depth of 3 feat: -Water table depth � l SEPTIC TANK ❑ Type lMfg apacity No. Compartments f PKG. TREATMENT PLT.❑ Method of Disposal Distance to no Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation-` ---1 l --Property Line DISPOSAL PONDS 0 l 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 workman's compensation laws of California." Contractor's hiring or subcontracting signature p certifies the following: "I certify that in the perlormance of the work for which this permit is issued, I shall smplay persons subject to workman's compensa- tion laws of California." The applicant must cal all required ins tions. Complete drawing o reverse side, Y Signed t V t Title: �R-.0 Date: OR DEPARTMENT USE ONLY i Application Accepted by Date — (,�,_ !Area Pit or Grout Inspection by Date Final Inspection by �` 444 , Date t -z-slq( Additional Comments; Applicant - Return 111 copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O SOX 2008, STOCKTON, CA 85201 FEE AMOUNT DUE AMOUNT REMIT7E0 CK RECEIVED BY INFO /�/� CASH DATE PER NO. Ek 13•24 IflEV.a i n 51 O r,CDC 11 i 2 J 0n ry . EFF.l.m T� ]CC] �T i11