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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 rIT EXPIRRa 1 YEAR omplete in Triplicate) Application is hereby made to an Joe in CoUnty for a permit to construct and/or install the work herein described. This application is made in eoWli nce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,C T�, _� Job Address S rr f�-tl/ S 'w t t"wx,'�_ C401101Z City Lot Size/Acreage s(-tf w_-1ne 1 11741vt l jos+ JR L/trn C44- /XI-) Owner's Name Address Phone PK- ~x�� 4[ !"n Contractor 0-)CC r-e-- Address(161 4 CA""AT ___ License No. 24tEy 1_ PhonLIP)Gn—b 1 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION U SYSTEM REPAIR E) OTHER )C Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS TJ f71 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation 1�a, of Well Casing U Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing -260 4-16Specificat.tons M Public 1-1 Other © Delta Depth of Grout Seal Type of Grout Cl hrioation —.Approx. Depth ❑ Eastern Surface Seal Installed by F_- �'•w� i �'G ~!'a'L Repair Work Done U Type of Pump H,P, State Work Done W +m ibtJro-r Well Destruction o well Diameter Sealing Material & Depth y Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION 7-1 DESTRUCTION D INo septic system permitted if public sewer is available within 200 feet.I installation will serve: Residence— Commercial T Other 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 �p PKG. TREATMENT PLT. D Method of Disposal ,I. Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line i SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O u _ 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 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant $t irad inspections, Complete drawing on reverse side, Signed Title: JCA- Date: ?. / 'V FOR DE AR ENT USE ONLY a Application Accepted by Date Area 44Ul Pit or.Grout Inspection by Date Final Inspection by Date Additional Comments; Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 SOX 2008, STOCKTON, CA 85201 INFO FEE AMOUNT DUE AMOUNT REMITTED (CK RECEIVED BY DATE PERMIT NO. . EH 17-24 iREV.I/R st 7! �j ��r \ ��I^ i I l '— O EH*X d L�