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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES IJ- P HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 0 (209) 468-3447 YEAR (Complete in Triplicate) ��""" Application In hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in comp"liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. S'z lea Job Address I� City Lot Size/Acreage Ste^ A Owner's Name . � �t , p�AA Address L- Phone ContractorI�. Address y!.S^i �'_O-_ License No.`�� Phone `�r TYPE OF WELL/PUMP: ! NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION Out of Service well Gl PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom 0 Manteca Dia, of Well Excavation — Dia. of Well'Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public f 7 Other 0 Delta Depth of Grout Seal Type of Grout � 4 0 Ifrigation Y. ApproR. Depth 0 Eastern Surface Seal Installed by Repair Work Done U Type sof Pump H.P. State-Work Done _ Well Destruction O Well Diameter Sealing Material A Depth s Depthi riller Materiel i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION CT DESTRUCTION.CI-tNo septic system permitted if public sewer is available within 200 feet) " Installation will serve: Residel�ce .:._ Commercial Other M Number of living units: °� Number of bedrooms Character of Boil to a depth of 3 feet: z { Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ (M Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE,. Cl NoF & Length of lines Total length/sire FILTER BED. n Distance to nearest: Well Foundation Property Line I� SEEPAGE PITS 11 Depth Size Number SUMPS Ll Disiance to nearest: Well Foundation Property Lina DISPOSAL PONDS o 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 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." Contractof's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this p@rmt s issued, I shall employ personi subject to wo -man's compensa- tion laws of California." I�. iiiwork-man's - The applicant must call for all regluired ins ctions,-Complete drawing-on-revefse'side. Signed , iI[ Title: 5!a-Lr Date: FOR DEPARTMENT USE ONLY Y�v —. «_ -- Application Accepted by P' Data Area ✓" �` + Pit or Grout Inspection by Data Final Inspection by Data Additional Comments: I� Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES II 445 N SAN JOAQUIN, P O BOX 2009, STOCKTOON. CA 85201 FEE INFO ,+AMOVNT;�Ot1E AMOUNT REMlTTEO CASH RECEIVED 8Y DATE PERMIT'NO. . CH 13.74 CREV.1/K51 '/ '" ` / _Za� [ 1 �-! �L� ,�F EN 14. „ / 1 [ (tel _ II