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I APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERI[ T E%PIRES 1 YM F&QM- DATE S (Complete in Triplicate) Application is hereby made to Sas Joaquin County for a permit to construct and/or install the work herein described. Thie application is made in compliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San Joaquin County Public Health Services. !l, 1 _ „ Job Address S• G �= City z- Le - Cot Size/Acreage Owner's Name ' i�ddress le I � F � Phone H Contractor # Address. _.(,�® !'a'��'r _ ?� License No. }��2-7L Phone A,c TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 -- OTHER ❑ Monitoring Well n PUMP INSTALLATION ❑ SYSTNf`REPAIR-❑"� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i, FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Botiom El Manteca Dia. of Well Excavation Dia. of Well Casing (l Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications i I1 public I"1 Other e Cl Delta M Depth of Grout Seal Type of Grout I i Irrigation► —Approxi rf I Depth I I Eastern "-Suace Seal installed by Repair Work Done U Type of Pump H.P.. Stats Work Dona { i' i n W WaN Destruction Well DiameterSealing Material Depth . T r 5j Filler Material E Depth ; F Depth f TYPE Of SEPTIC WORK: NEW INSTA;LLATI N I 1 REPAIA1ADDITION i I DESTRUCTION INo septic system permitted if public sewer is l 1 available within 200 feet.) ( ) Installation will serve: Residence—{ Commercial— Other Number Number of living units: Number of bedrooms ..-- Character of soll to a depth of 3 feet: E I Water table depth SEPTIC TANK ❑ Type/Mfg) Capacity No. Compartments _ Method of Disposal PKG. TREATMENT PLT. ❑ f ` Distance to nearest: Well foundation Property Lina LEACHING LINE 0 No. 15 Length of linea Total length/size FILTER BED ❑ Distance to nearest: Well i ----Foundation- 1 Property Line SEEPAGE BITS 11 Depth I Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line y. DISPOSAL PONDS ❑ r' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and rules and regulations of the San Joaquin:County Home owner or licensed agent's iignature certifies the following: 111 certify that in the performance of the work for which this permit is issued, I shat)not employ any person in such manner as to become-subject-to-workman-s-compensation-laws•of-Californis."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, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspgctions. Complete drawing on reverse side. Signed Title: Date: DEPARTMENT USE ONLY Application Accepted by 44 Date — p Are,- Pit or Grout Inspection by Date Final Inspection by r Date Additional Comments: did r a Applicant - Return all copies to: San Joaquin Co my Public Health Services Environmental Health Permit/Services k� 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEr INFO AMOUNT OtlE AMOUNT REMITTED K RECEIVED 8Y DATE PER . EFI 13-2+IItEV.„Ker !� l E3f t42a