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.I APPLICATION FOR PERMIT i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 .e (209) 468-3447 XBRUIT—MIRES„ 3. YEAR PROM RATE_ SSUEp (Complete in Triplicate) itAppllcation ie hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This :Application 1a made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules a.nd Regulations of San rJoaquln County Public Health Services. Job Address City • Lot Size/Acreage 4 i1 Owner's Name Address Phone Contractor tA- Address r License fVo. Phone 0 TYPE OF WEL / U P: _ NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service We11 C1 PUMP INSTALLATION C1 SYSTEM REPAIR C] OTHER 0 Monitoring Well DISTANCE TO NEAREST: EPTIC TANK SEWER LINES - DISPOSAL FLD, PROP. LINE `f �f FO DATION AGRICULTURE WELL OTHER WELL PIT SISUMP$_I INTENDED USE TYPE WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial D Open Bott ❑ Manteca Dia. of Well Excavation �� /Dia of� Well Casing U Domestic/Private 0 Gravel Pack D Tracy Type of Casing /5pecifiCations G Public EI Other 0 Delta Depth of Grout Seal Type fi Grout ' r*I Irrigation Approx. Depth astern Surface Sea] tnstalk by Aapair Work Done U Type of Pump H p / State Work Done Well Destruction ❑ Wall Diameter Sealing Material i Depth 4 Depth ler Material & Dep'h TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIA ITION C-�uLb tRUCTIO I (No septic system permitted if public sewer is available within 200 last.) -Onstallation will serve: Residence,. Commercial— Other , Number of living units: Number of bedrooms �F ,Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. C3 !� Method of Disposal Dist to nearest: Well Foundation roperty Line LEACHING LINE 0 No. &.Length of lines Total length/sire FILTER BED n Distance to nearest: Watt Foundation _ Property Line , PAGE PITS l I Depth 5u® Number SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, tate laws, and l rules and regulations of the San Joaquin County Home owner or licensed agent's signature cartifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any parson 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 certify that in the performance of the work for which this permit is issued, t shall employ parsons subject to workman's compenure tion laws of Colifornla." sa- The applicant u t I or if rept i d spections. Comp) a drawing on re rse side: Signed , Title: Date: 4 FOR DEPARTMENT' USE ONLY Application Accepted by '' Dale A a ' Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: d:III Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES A + i ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, p 0 BOX 2009, STOCKTON, CA 95201 4 j FEE AMOUNT DUE AMOUNT REMITTED CK _� INFO RECEIVED 8Y DATE PERMIT N0. 11 J , • EH 14,2 (REV.