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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 REMIT EXPIRES I YEAR FROM DA3:E ISSUED (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 cowliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City � � Lot Size/Acreage 1i Owner's Name Address r Phone Gk-,Ya Contractor uw, Address I License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well E7 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 O Open Boitorn ❑ Manteca Dis. of Well Excavation Dia. of Well Casing U Domestic/Private CI Gravel Pack ❑ Tracy Type of Casing Specifications [D Public fel Other- - p Delta Depth of Grout Seal Type of Grout M Irrigation .� Approx. Depth 0 Eastern Surface Sedl Installed by 1 + Repair Work Done U Type of Pump H.P. State Work Done _ 0 Well Destruction 0 Well Diameter Sealing Material I6 Depth Depth Filler Material i Depth j TYPE OF SEPTIC WORK: NEWINSTALLATION 0 REPAIR/ADDITION DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.l V f Installation will serve: Residence_ _ Commercial r Other Ree,zzice 1 ckeri Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. .4 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, n Method of Disposal l Distance to nearest: Well —� Foundation b _ Property Line 552 x 1 LEACHING LINE L❑ No. & Length of lines Total length/size FILTER BED 11 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ rules and regulations of the San Joaquin County 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 e Home owner or licensed agent's signature cenifies 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 sub-contracting 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- tlon laws of California." The applicant must call for all ui1�9ns lions. Complete drawing on reverse side, I Signed Tide: Date: FO TMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 0 Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMl7'NO. INFO CASH EM t]-21IREV.wins! /y4�0 Ex'.4 20 [J