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APPLICATION FOR PERMIT +^ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �0 � � 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT M IRES 1 YEAR FROM DTE ISSUED4 (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 coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Seervices.f� t/Job Address �75/ L S City Lot Size/Acreage Owner's Name Address Y �� Phone AContfactor Address .1 License No. Phone ITYPE Of WELL/ MP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well Cl 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 T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ci Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications l'I Public la Other Cl Delta Depth of Grout Seal Type of Grow I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter i!Sealing Material i Depth Depth ;Miller Material i Depth F SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I 1 DESTRUCTION lNo septic system permitted ' u lic sewer is available within 200 1 Installation will serve: Commercial— Other Number of living units. Number ems Character of sol to a depth of 3 feet: Water table depth } SEPTIC TANK O Type/Mfg apacit No. Compartments PKG, TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well, oundation rty Line LEACHING LINE L1 No. 8 Length of lines Total length/sire' FILTER BED ❑ Distance to 1: Well Foundation Property Line r SEEPAGE PITS 11 pth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL:6-S ❑ 2 1 hecertify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and and regulations of the Sen 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 conifi"the following:"I certify that in the performance of the work for which this permit is issued, I shall amploy persons subject to workman's compenss- tion laws of California." The applicant call for I requir inspections. Complete drawing on reverse side. ><$igned Title: L[J.11z.eyi _.. Date: ` FO EPARTMENT USE ONLY q 9 # Application Accepted by {^^� Date I d t i L Area 02 Pit or Grout Inspection by Date y Final Inspection by Data Additional Comments: -Applicant - Return all copies to, San Joagtiin- County Public Health Services a Environmental Health Permit/Services ' 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE INFO AMOUNT DUE AMOUNTREMITTED K ECEIVED BY DAT PERMIT NO. • EM 13.24(REV.it 51 CH 14.25