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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION Y � RECEIVED P 0 BOX 2009, STOCHTON, CA 95201 ° S'_P 0 8 ' � z (209) 468-3447 SAV JOAQ[iIN M',INTY YZAR PROM RATE ISSUED SEP PUBLIC HEALTH SE§1 CES - (Com ENVIRONMENTAL HEALThf [�i`��;S;I,y piste in Triplicate) VlRQNM �yT �_ !�l A W Application is hereby made to San Joaquin County for a permit to construct and/or install theP+ lilltl � � This Application,is made in compliance with San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulati�jons of San Joaquin County Public Health Services. Job AddressOB!lf City at Size/Acreage w�. I) Owner's Name dress _.. _ . _ Q–S�-r? 4¢ .,,,, Phone Contra c re 7coioKense —Phone Z87E] w TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ t�� PUMP INSTALLATION SYSTEM REPAIR C4—' OTHER ❑ Monitoring Well �� w 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 Y ..0 0 Industrial^� ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 9�4OM_estic/ C3 Gravel Pack 0 Tracy Type of Casing Specifications M Public - 11 Other ❑ Delia Depth of Grout Seal Type of Grout CI lrrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work poneType of Pump H.P. State Work Done d Well Destruction ❑ Well Diameter Sealing Material 4 Depth Ar Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION L-1 REPAIRIADDITION 71 DESTRUCTION 0 JNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: ResidenceY� Commercial— Other ((0111 Number of livingunits: i� INumber of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal I Distance to nearest: Well Foundation Property Line i i LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Fl Distance to nearest: Well foundation Property Line I SEEPAGE PITS I I Depth Size Number SUMPS Ll 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 1 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 i employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature cartifles 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- I tion laws of California." , The applicant must c f all required i -tions. Complete drawing on r verse side. Signed Title: .�C..�1—� Date: FOR DEPARTMENT USE ONLY Application Accepted by4 r Date I2 T Area Pit or Grout Inspection by Date Final Inspection by ats��Z I Additional Comments: Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES T ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCHTON, CA 65201 FEE AMOUNT DUE AMOUNT REMITTED GK RECEIVED BY DATE PERMI7'IVO. INFO CASH . f>i I3•741REV.rinSr �-. WW �� 3��ela.3--