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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468--3447 YEAR PROM DATE ISSUED (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 i Joaquin County Public Health Services. r Job Address y City S�aG %?',t Size/Acreage r _10 Owner's Name " Address ��y�� —_ Phone • Contractor i' {1fess <CEn5B 11O.112✓177 Phone R� i TYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMENT CI DESTRUCTION J-eut of Service Well LI l PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 M Industrial ❑ Open Bottom ❑ Manteca Die, of Well Excavation Dia. of Well Casing W160`me3tic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public ill Other ❑ Delta Depth of Grout Seal Type of GrouJC&7__& Gi Irrigation Approx. Depth tern Surface Seal Installed by Repair Work 'Done LJ Type of Pump H.P. State Work Done— Well Destruction �Well Diameters Sealing Material i Depth I 'Depth / Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIR/ADDITION M DESTRUCTION G INo septic system permitted if public sewer is41- ` available within 200 feet.) Installation will serve: Residence— Commercial,_ _ Other Number of living units: Number of bedrooms { W , Character of soil to a depth of 3 feet:I Water table depth SEPTIC TANK ❑ Type/Mfg. # Capacity No. Compartments PKG. TREATMENT PLT. ❑ + . a Method of Disposal Distance to nearest: Well Foundation Property Line, +� ' LEACHING LINE C] No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line \11 r SEEPAGE PITS w� I I Depth Size Number SUMPS t Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wi$l 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 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 sub-contracting signature certifies the following: "I certify that in th rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant s all If re Ir on , Com to drawing on raver s+d 1' s Signed X Title. - Dater L!,/ OR TMENT USE ONLY Application Accepted by Date fes► _ Area Pit or Grout Inspection by_ Date Final Inspection by ,- - Date L Additional Comments. _ Applicant - Return all copies to: SAN JOA IN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 88201 FEE INFO AM UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, EM 13•211REV.i/hsi &00-0 ; C?()EN 114-20 V