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N APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 209 468-8447 l PERMIT ESBIRES 1 YBAk PROM DATE ISSUE (Complete in Triplicate) Application is hereby ntnde to San Joaquin County for a permit to construct and/or install the vork herein described. This 9 application is wade in compliance with San'Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I � -- Job Address Y�� "P - City Lot Size/Acreage Owner's Name I � ddress - Phone 9 i Contractor �+/�NS ddress License No.�_Phone 3 TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service We PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Mon- 4 oniwel DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF,IWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Die, of Well Excavation Dia. of Well Casing U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications M Public CI Other I - ❑ Delta Depth of Grout Seal Type of Grout CI Irrigation ^Approx. Depth ❑ Eastern Surface Sell Installed by Repair Work Done' LJ Type of Pump H.P. State Work Done Wall Destruction O Well Diameter Sealing Material & Depth _ I' 4+�1 Depth i )Piller Material 4 Depth TYPE OF SEPTIC WORK; MEW INSTALLATION❑ REPAIR/ADDITION Cl DESTRUCTION CI INo septic system permitted if public sewer Installation will serve: Residence l Commercial— Other available within 200 feet.i 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. Q 1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED n Distance to nearest: Welt Foundation Property Line SEEPAGE PITS 11 Depth I Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 - 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 9 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 cenifies 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" i The applican c t requ c ' Complete drawing on rev se-side. Signed itle: ° Date: D 'Fl USE ONL Application Accepted by Dau!.: .Ari Pit or Grout Inspection by S Date ,l��Q/� �� Final Inspection by, Date t Additional Comments; Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES )ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICESy✓ k 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON. CA 9520141� 1 609;&WA [ FEE AMOUNT DUE AMOUNT REMITZEO t K RECEIVED BY DATE PERMIT'NO. INFO CASH �, • EH t,.�tREV.�I x Sr �Q.� � � ` � !� L �� —V � -ate