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APPLICATION FOR PERMIT � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 UMIT ESPIRFS 1 YEAR PM PATE I�SaM (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in ccWliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County, Public Health Services. Job Address 3 � � ��-1 wo d City U Lot Site/Acreage Xowner's Name -)6 2 -f kY 11-IiI Address 3 � Phone �� 41 �es-/ mak- Address License No. Phone ___111IIITYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well D PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER O Monitoring well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n tndustrial D Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private D Gravel Pack C] Tracy Type of Casing Specifications M Public Cl Other C] Delta Depth of Grout Seat Type of Grout 0 Ifrigalion —Approx. Depth ❑ Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Welt Diameter Sealing Material 4 Depth Depth Filler Material i Depth IN TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION V lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence' , Commercial Other Number of living units: tJumber 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: Well Foundation Property Line LEACHING LINE. ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, $tate laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I cenify that in the performance of the work for which this permit is issued, t shall not 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 certify that in the parlormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa� tlon laws of California." Thea ppI' an must call for sU regyired inspections. Complsta drawing on reverse side. Signed Title: .. } Date: DEPARTMENT USE ONLY Application Accepted by Cw� `� ^ � .a�.�. .. Date Area Pit or Grout Inspection by Date Final Inspection byDate l D Additional Comments.- Applicant omments:Applicant - Return a1.1 copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOR 2009, STOCKTON, CA 05201 INF EEE AMOUNT DUE AMOUNT REMITTED -CASH RECEIVED BY DATE PERM17'NO. a EN 15-24iREV. Eh I/As) 7 v7 J r- -�^ M .l.26