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APPLICATION .FOR PERMIT � SAN! JbAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERM T ESPIRES 'YE FROM D TE ISSUEDj ,A (Complete in Triplicate) Application is hereby made'to $an Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r ,/Job Address �` k " ' `" City r""' , t Size/Acreage Owner's Name _ r � Address J. Phone 33� Contractor V Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER 0 Monitoring Well C] DISTANCE TO NEAREST: SEPTIC TANK . -SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom; 0 Manteca Dia. of Well Excavation Dia. of Well Casing � I n Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_.. Specifications Il Public 1-1 Other " ' n Delta Depth of Grout Seal Type of Grout I I Irrigation w Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter + Sealing Material i.Depth Depth Tiller Material pth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I DESTRUCTION I No ptic system permitted if public sewer is ble within 200 feet.l Instal a' will serve: Residence Commercial _ Other ------ Number of IM-- ' s: Numbeitof bedrooms Character of soil to a dap 3 feet: f or table depth # SEPTIC TANK ❑ Type/M g t t Capacity No. Compartments 1 PKG. TREATMENT PLT.❑ � Method of Disposal Distance to nearest: Well_---. F ation Property Line . LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED 0 Distance to near Well Foundation Property Line ` SEEPAGE PITS '11 Ih f j Size" Number SUMPS I Distance to nearest:I Well Foundation Property Line 11 DISPOSAL P ❑ I her enify that t have prepared this application an t at the work will be done in accordance with San Joaquin county ordinanco,71ftteotz, and s 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 shell not r employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I unify 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." the applicant must c for all requin pgctions. Co late drawing on to& side. � g Xsigned Title: �FC-r"r Date: ! r> _. -FQ --_E_ONLY -�T-�-�•� ' Date Are,-02 Z - Application Accepted by Ph or Grout Inspection by Date Final Inspection by Date Additional Comments: f Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services k 445 N San Joaquin, P O Boa 2008, Stkn, CA 95201 ' FEE INFO AMOUNT DUE AMOUNT REMITTED GAS RE EIVEO BY DAT PEfIMIT'NO. - 00 + EM 1t34.2a46 IRE1. h61 Ch -�