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APPLICATION F'OR PERMIT 4 • �1 � Up SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) .468-3447 PEMIT EXPIRBS 1 YEAR _rM DATE ISSUE (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 compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulationii of $an Joaquin County Public Health Services. Job Address �""r - City N Lot Size/Acreage Owner's Name -- - - - — Address Phone ' Contractor 4= Address — License No. Phone ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well [7 DISTANCE TO NEAREST: SEPTIC TANK'Z." "" 'SEWER LINES - DISPOSAL FLD, - -PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f] Industrial 4 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications M Public a -1 Other ❑ Delta Depth of Grout Seal Type of Grout 0 Irrigation t ,Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ED REPAIRIADDITION DESTRUCIION >"i .INo septic system permitted it public sewer is available within 200 loot.) 1N Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedroomsf Character of soil to a depth of 3 feet: Water table depth C SEPTIC TANKS ❑ Type/Mfg Capacity------- No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal f " Distance to nearest: Well Foundation Property Line r M LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED t n Distance to nearest: Well Foundation Property Line t SEEPAGE PITS Depth Z Sire d Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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: "l certify that in the performance of the work for which this permit is issued, I shall not I employ any person in such manner as to become subject to workmen's compensatibn laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify th t 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 applican c II r uirsd inspections, Complete drawing on reverse side. — Signs Title: Date., --1/ a F f� TMENT USE ONLY ; Application Accepted by ° Date l Area Pit or Grout Inspection by Date _ Final Inspection by Date 1 Additional Comments; !r" � ��y� - 8 / _. 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 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE /PERMIT'NO. r EH 1 .21 iREY.r/nil l t;ri;�•la /�