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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONIMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERU T EgPIRES 2 Y FROM DATE (Complete in Triplicate) Application is hereby made to Sam Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Joaquin County Ordi ce No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. tth�5 Job Address L��rl\ Vq City Lot Size/Acreage Owner's Name( e a( �,aldil5 Address �C� t� �So� Phone 3 Contractor Address 210 C�. ` v License No.2!292,A3 Phone F TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION XCkrt of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER 0 Monitoring well Ia 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing- Specifications 1'I Public F1 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H,P. tats Nor one _ Well Destruction ❑ Well Dih7er �� Sealing Material & Depth /C Depth I Tiller Material i Depth 19 -� -- -�-� O TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 lNo 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 soli 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 Li LEACHING LINE ❑ No. 5 Length of lines Total leng!t, //ire - FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Walt Foundation Property Line C 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. Mute laws, and rules and regulations of the San Joaquin County Homs 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 the performance of the work for which this permit is issued,I shall employ persona subject to workman's compensa- tion laws of California." The applicant must call for all uir inspections. Complete drawing on reverse si e. Sigft��4 Title: Date: 3 1Q FOR DEPARTMENT USE ONLY Application Accepted by 23tf Z DateArea� nZ. i Pit or Grout Inspection by Date incl Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services - - 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDECASH RECEIVED BY DATE AERM17'NO. INFO EH 11. 6IREV. i e si 3--{1-73 `t3-b�3