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APPLICATION FOR PERMIT y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . , ENVIRONMENTAL HEALTH DIVISION P. O BOX 2009, STOCKTON, CA 95201 �� C+ �' (209) 468-3447 CPBUIT EX R PROM DAIE ISSUM (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 trade in ceetpiiance with San Joaquin County Ordinance No. .549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 2 B E' C, r Job Address City Lot Size/Acreage C)f1 / � / y�Owner's Name SAddress 2 � / /r _ Phone X'antractor - - - Address License No. /tf Phone TYRE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REP IR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER L NES DISPOSAL FLD. PROP. LINE FOUNDATION AGR1 UL AE WE OTHER WELL PITS/SUMPS _ USE TYPE OF WELL PROBLEM AREA 0 TRUCTION SPECIFICATIONS atrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing omestic/Private .❑ Gravel Pack ❑ Tracy Typ of Casing Specifications Pubtic i 1 Othir ❑ Delta Dept f Grout Seal Type of Grout CJ IrrigationApprox. Depth ❑ Eastern Surface out installed by Repair Work Done LJ Type of Pump H.P. State Work pone Well Destruction O Well Diameter Sealing Material Depth i f 3 Depth Filler Material i Depth \ TYPE OF SEPTIC WORK:. NEW INSTAL' ION O REPAIR/ADDtT10N M DESTRUCTION INo septic system permitted if public sewer is r� available within 200 feet.l Installation will serve: Residence Commercial Other ' Number of living units: Numbef of bedrooms , Character of toil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ '. Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT. b' Method of Disposal I Distance to nearest: Well Foundation r Property Line LEACHING LINE ❑ No. & Length of lines Total length/aiza �1S FILTER BED _ [_i Distance to nearest; Well Foundation Property Line SEEPAGE PITS 11 Depth f 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 rules and regulations of the San Joaquin County i Home owner or licensed agent's signature dertifies 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 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, 1 shall employ persons subject to workman's compensa- tion laws of California.,, t 5. The applicant ust tail for all req ad inspections. Complete drawing on re roe$i {]t Signed q ' i V � Title: . Date: vt✓ OR �RTMENT USE ONLY Application Accepted by � - Area Date I Pit or Grout Inspection by Date Final Inspection by - V` { Da[a Additional Comments; ] Applicant - Return all copies to: t — P SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 4.45 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE OUNT Dt1E AMOUNT REMITTEDCK iT INFO CASH RECEIVED BY DATE PERMIT'NO.