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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION y S) P O BOX 2009, STOCKTON, CA 95201 1� (209) 468-3447 (Complete in Triplicate) Application Is hereby trade to Sen Joaquin County for a permit to construct and/or install the 10 e3$+,d ed11f�ile application is glade in compliance .vith San Joaquin County Ordinance No. 549 and 1862 and the Rule g>t i e 0W Joaquin County Public Health Services. Job Address �-r 4 City Lot Size/Acreage a Owner's Name ' Address �` �, �`��-s% Phone R � t-91w Contractor ddress GC .J ! / & License Nol 13_? _ phone ^R C-1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION CY SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINT: FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PRQBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing . U Domestic/Private D Gravel Pack to Tracy Type of Casing Specifications �1 ❑ Public 1:1 Other ❑ Delta Depth of Grout Seal Type of Grout _ n ICE Irrigation ,_.—.Approx. Depto [I Eastern Surface Seal Installed by Repair Work Done 23— Type of Pump H.P. .l .State Work Done _ h Well Destruction O Well Diameter ` Sealing Material i Depth —1-� Depth Piller Material g Depth TYPE OF SEPTIC WORK: NEW INSTALLATION_❑ REPAIR/ADDITION Ll DESTRUCTION CI (No septic system permitted if public sewer is available within 200 lest.l Installation will serve: Residence_ Commercial�-- Other - �^ Number of living units: Number.of bedrooms !� Character of boil to a depth of 3 feet: ~ T 17 Water cable depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments_ PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest:z Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Total length/size f FILTER BED n Distance to nearest:: Well Foundation Property Line r SEEPAGE PITS If Depth Size Number SUMPS Ll 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 shell 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 j certifies the following: "I certify that 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 applicant at call for all required insp�ctions.�C_oom_plete drawing on reverse side, Signed �`� Title: Date: > FOR DEPARTMENT USE ONLY Application Accepted by Date — a Area Pit or Grout In y Inspection b t Date Final Inspection by Date 2—/ l 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 2008, STOCKTON, CA 65201 FEEi INFO AMOUNT fDUE AMOUNT REMITTED CASH CK 9 RECEIVED BV DATE PEAM11 NO. �H 1�-21111 t;V.7/M51 � �{/ .�` 1 •r�' (�i