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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIAENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED T (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 1862 and the Rules and Regulatione of San Joaquin County Public Health Services, Job Address ' City Lod { Lot Size/Acreage Cfs Owner's Name . T`t� W Address _ � � __ Phone M Contractor � `� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well L1 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (71 Domestic/Private ❑ Gravel Pack7 PackL] Tracy Type of Casing_ ptil Specifications l'1 Public n Other fl Delta Depth of Grout Seal Type of Grout 141 Inigation —.Approx. Depth I I Eastern Surface Seal Installed by n Repair Work Done Type of Pump H.P.' State Work Done jL\%V_2' . C kz Well Destruction 0 Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I Mo septic system permitted it public sewer is W available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units; Number of bedrooms Character of soli 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: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS C1 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 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 empkry any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature mortifies the foTom tify that in the performance of the work for which this permit is issued,1 rhaN employ persons subject to workman's compensa tion laws.of CThe applicant ui nspectiops. gomplete drawing on reverse side. z Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Data { , jZ Area Pit or Grout Inspection by r / Date Final Inspection by w Date !Z Additional Comments: t'C3`Q v Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 6 , Stkn, CA 95201 FEE INFO AMOOUNNT112-5 ^ ,D�U/E� AMOUNT REMITTED CASH K 1 CE VED BY 1,"l,DA�]TE G PERMIT'N0. « EN 1121(REV.I i n s) t7L/ �0t7 � ` ( f � 1 EH 11.2e /v