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APPLICATION FOR PERMIT f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 l REMIT MWIR90 1 YEAR..1%4,�[ DATH_jSSUSQ (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 c=wliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services/ Job Address """S City � ` , Lot Size/Acreage- _- _ -- Owner's Name d PI!!Q �q r Address o2171 6 -14$ • -5�' 79/T-3 2 s� Phone } ContractorAddress `r"'"`c License No. Phone _ ^f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 0,PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [7 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 L�.Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private L-7 Gravel Pack ❑ Tracy Type of Casing Specifications LD Public (71 Other 0 Delta Depth of Grout Seal Type of Grout 0 IfriUation ,_,_.Approx, Depth ❑ Eastern Surface Seal Installed by 1 Repair Work Done (3 Type of Pump H,P. State Work Done � M Wall Destruction 0 Well Diameter Sealing Material & Depth �) i Depth Filler Material i Depth s TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION M DESTRUCTION {No septic system permitted if public sewer is i available within 200 feet.) Installation will serve: Residence Commercial_ Other V Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, C1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Silo Number SUMPS Ll Distance to nearest: Well Foundation ' Property Line DISPOSAL PONDS ❑ 4 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 j rules and regulations of the San Joaquin County Nome 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 E employ any person in such manner as to become subject-to workmen'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 m call for all required i coons. Complete drawing on reverse side. Signed _ .�s�trtic� --�„ ., Title Date: �/” r FOR DEPARTMENT USE ONLY Application Accepted by Dare Pit or Grout Inspection by Date Final Inspection by Date r Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 1 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE AERMIT NO. INFO CASH t . EM 741REV.�,r�i 7 r rx' _N, eM. // & 31oS - i