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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 . PERMIT EgPIRESYEAR FROM DATE ISSUED (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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. J� City Lot Size/Acreage Job Address ' l ,S D t Owner's Name Address _ Phone or+tractor _ _Address License No. Phone T PE OF WEI /PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ 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 I-) Industrial ' ❑ Open Bottom ❑ Manteca f . 'f Dia. of Well Excavation Dia. of Well Casing C.1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications i1 Public Cl Other' fl Delta Depth of Grout Seal Type of Grout I 1 Irrigation —.Approx. Depth 'I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H,P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth -Piller Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION 14 DESTRUCTIONlNo sept wsystthin m permitted if public sewer is Installation will sero: Residence— Commercial— Other ' Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal {. Distance to nearest: r Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total lengthlsize FILTER BED ❑ Distance to nearest: ' Well Foundation Property Line SEEPAGE PITS It Depth Size Number SUMPS Ll Distance to nearest: - Well Foundation Property Line DISPOSAL 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 p- 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 shell not employ any person in such manner as to become subject to workman's compensation laws of California:'.' Contractor's hiring or subcontracting 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 compenss- tion laws of California." f` 4 The applicant must call for ell required inspe.celons. Complete drawing on r se sada. r� q �/ / Date: _� X r IU,1L ISy� It'Ilk __ Title: RQKPARTMENT USE ONLY VL Application Accepted by - Date Area D Ph or Grout Inspection b (� Date Final In coon b Oats 1 Additional Comments: `� Applicant - Return all copies to: Saa J quin County tic Health Services DW �'^•-d 01'( Eavir ameetai Health Kermit/Services �� r 445 San Joaquin, P 0 Box 2009, Stkn, CA 95201 r i yrt Com[. FEE AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY GATE PERMIT NO. INFO . EH 1344(REV.I/PI5)5D ,o-o-74 EH 14.26