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pi � APPLICATION FOR PERMIT ;,. h ,. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -I _ ENVIRONMENTAL HEALTH DIVISION T P 0 BOX 2009, STOCKTON, CA 95201` (209) 468-3447 ENIVIRONNiENTAL HEA Til (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 trade in c=Wliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of San Joaquin County Public Health �Service Job Address �([J `a-�"r City Lot Site/Acreage Owner's NemL dres�_44?,� _ Phon Cantracto A ress ' 1cense No. Phone Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L7 DESTRUCTION ❑ Out of Service well Ll PUMP INSTALLATIOf SYSTEM REPAIR ❑ OTHER ❑ Monitoring well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE n FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS to Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Did. of Well Casing .—e4ulestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications ` l M Public CI Other ❑ Delta Depth of Grout Seal Type of Grout M Irrigation Approx, Dept ❑ as rn A /5� ea Seal Installed by Repair Work Dons ❑ Type of Pum H.P. / State Work Don •e r Sealing Material & Depth Weir Destruction ❑ Well Diemeta� - - Depth 7-1 Filler Material 4 Depth ` TYPE OF SEPTIC WORK; NEW INSTALLATION❑ REPAIRIADDITION M DESTRUCTION 0 (No septic system permitted if pub )sews is available within 200 loot.) Installation w4i serve: Residence..T„- Commercial T Other Number of living units: Number of bedrooms f Character of soil 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 C LEACHING LINE Cl No. & Length of lines Total length/size F FILTER BED n Distance to nearest; Well Foundation Property Line r SEEPAGE PITS 11 Depth Sire ; Number r SUMPS El Distance to nearest: Well Foundati n, Property Line � DISPOSAL PONDS ❑ - I hereby canify that t-have prepared this application and that the work will be dons`in accordance with San Joaquin county ordinances, state lawC-and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the perlormance 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-it issued, I shall employ persons subject to workman's compensa• tion laws of California." t a The applican ,u t call for re uir inspections. Complete drawing on to sa sida Sig d Titl - Date: FOR DEPARTMENT USE ONLY ) Application Accepted by Date 0.7/' f?o' Arse a r Pit or Grout Inspection by Date Final Inspection by Date 2 2 Additional Comments; Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 11•N IREY.t/M61 fFl �� 13- oZ O1 YL 6(,t3 i�•I6 V r r DA1