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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SGT� :. Sr =� (Complete in Triplicate) ' Application is hereby made to Ban Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I C;t t Lot Size/Acreage Job Addre Y 9Owner's Name Address - - � Phone ContractConlran 0,-J.IA. hon TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ , Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'1 Public 1-1 Other f7 Delta Depth of Grout Seal Type of Grout oo I I IrriUation _Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. tato Work-Done Well Destruction ❑ We"Diameter- -SeaXing Material A Depth d- t Depth cal Q -_ - Filler Material i Depth O TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION [ I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of loll to a depth of 3 foot: Water table depth SEPTIC TANK O Type/Mfg Capacity No"Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 11 Depth Size Number , SUMPS LI 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 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: 'Y 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." The applicant ust cal or all required inspectiggs. Complete drawing on reverse side. Sig4T Y,2,6Title: PG Date: _ F DE4RTMENT USE ONLY { ! Application AeeeNtar byLi Date 1 0 Area QZ e Pit or Grout Inspection by Date Final Inspection by Date �2 Additional Comments: 6th-ge.CW LY Y—fstjL�1 ,CA4 Applicant - Return all copies to: San Joaquin County PublicHealth Services V 'e- Environmental Health Permit/Services .* 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE y�y 1IN'FO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY ATE PERMI7'NO. . EM 13 24 111EV,t i n 61 -/ aw {. 1 EM 142e