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. APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 (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 ttmde in compliance with San Joaquin County Ordinance No. 549 and 1852 and the Rules and Regulations of Ban Joaquin County Public HeServices. Job Address 415 a�/1 �City � Lot Size/Acreage �O alt Owner's Name i�, --: s /p Address Phone Contractor `t + `1'lf-t^C,— Address tAJ O License No.L43 O&D9 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing C1 Domestic I Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications M Public CI Other 0 Delta Depth of Grout Seal Type of Grout CJ tr6gation Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H-P. State Work Done Wall Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE Of SEPTIC WORK; NEW INSTALLATION 10--REVAIR/ADDITION M DESTRUCTION CI (No septic system permitted if public sewer is r available within 200 lool.1 V Installation will serve: Res'denca Commercial iOther s _ Number of living units: Number of bedroom �L Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Ort4ef:.ter _ Capacity I r No. Compartments PKG. TREATMENT PLT, M Method 9f uposal r Distance to nearest: Well Foundation s Property Line !r, LEACHING LINE ❑ No. S Length of tines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Nue%ber SUMPS L_-DTVa ce to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ D 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 certifies the following: .I cenity 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 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 applic u t call all requ din cti omplete drawing on r arse std Signed DEPARTMENT •• $ _ 9 Title: Date: F DEPARTMENT USE ONLY -- Application Accepted by Data Area_. q Pit or Grout Inspection by Data Final Inspection by Date l C� Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 lM E OUNT DUEMOUkT REMITTED CASH RECEIVED BY DATE PERMIT NO.