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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)465-3420 P O BOX 2009, STOCKTON, CA 95201 PERM[ T EXPIRES 1 YEAR FROM DATE I.SSIZED (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job AddressQrlCity Lot 31ze/A reege 4 t- �7 �yl 1�, m� Owner's NameL_��p] `��k1 caress o � Phone Contractor Address a2 I icense Nov�b, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ Monitoring well ❑ 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 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 17 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done n 1 Well Destruction ❑ Well Diameter Sealing Material Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 fest.) Installation will serve: Residence_ Commercial'*_ Other Number of living units: Number of bedrooms Character of sail 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 1 LEACHING LINE ❑ No. & Length of lines 'W Total length/size FILTER BED ❑ Distance to nearest. Wetl4= Foundation 2e) � Property Line SEEPAGE PITS Depth Site Number SUMPS Ll Distance to nearest: Well Foundation A Property Line ED DISPOSAL PONDS ❑ 1 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 Horne owner or licensed agent's signsture 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 subcontracting 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 compenss- tion laws of 'fornia." The apple t st call for requi inspections. Complete drawing verse side. y n Since Title: Date: _)+,( � OR DEPARTMENT USE ONLY rr, Application Accepted by Date t` t- Area Pit or Grout Inspection byDate Final Inspection by Oate �a l� 9?✓ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO.