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d r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION F 445 N SAN JOAQUIN, PHONE (209)468-3420 x P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES l XM FROM DATE ISSUED (Complete in Triplicate) '. Application is hereby made to Ban Joaquin County for a permit to construct and/or inatall the work herein described. This application is made in cotapliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /Job Address _ o Lot Size/Acreage � �f _- Owner's Name Address C� Phone( E��l. +s- Contractor - ' Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CI DESTRUCTION o Out of Service Veil ❑ PUMP INSTALLATION ❑ .. . SYSTEM REPAIR ID OTHER ❑ Monitorltlg 41@11 0 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 n Industrial "❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing EI Domestic/Private ❑ Gravel Pack El Tracy type of Casing Specifications \ f ('i Public s "Cl Other""""""'"' f'1 Delta' $" '""'Depth of Grout Seal'' - Type df Grout-, I i Irrigation —Approx. Depth i I Eastern Surface Seal installed by Repair Work Done U # Type of Pump a` H.P. State Work Done_ e ~^ Seals Material i Depth Well Destruction ❑ Well Diameter - R 1 r Depth filler Material i Depth EFILTER F SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I P DESTRUCTION-1-1-INo septic.system permitted if public sewer is available within 200 feet.) Installation will smvs: #Residence Commercial Other er of living units: . Number of bedrooms * -- ter of soq to a depth of 3 feet: Water table depth TANK O Type/Mfg Capacity d 1O No. Compartments TREATMENT PLT.Ll r Method of Oispogal Distance to nearest: well Foundations Property Line NG LINE No. a Length of lines - Totalrlength/aixe BED �❑ Distance to nearest: Well Foundation � S— Property Line k isE PITS IM Dpth Size Number LI Distance to nearest: Well V1 Foundatio • 'F Property Lint L PONDS ❑ 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 sub-contracting signature d certifies the following: "I certify that in the performance of the work for which this permit is issued. I @hall employ persons subject to workman's compensa- tion laws of California." The applicant at call for avrequired inspections. Complete drawing on reverse side. / +f u Signed f r Title: Y �/�= �- Dater l\ _ARTMENT USE ONLY Application Accepted by Date -� Area fTit�br Grout Inspection by� Date / Final Inspection b � �Data7_ ____� Additional Comments: t , Applicant - Return all copies to: San Joaquin County 'Public Health Services Environmental'Healtb Permit/Services 445 N San Joaquin; x 2009, Stkn, CA 95201 r FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED By DATES PERMIT-NO. INFO i EH 14,21124 i11Ev.l i n s� [ fH 1 t 0O .0 0