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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION L P O BOX 2009, STOCKTON, CA 95201 (209) 468--3447 JAN 2 4 �NVrte N A �. P S _ (Complete in Triplicate) P `3'"� �4_01Vr . Application LB hereby mad t: San Joaquin County for a permit to construct and/or install the work herein described. This fi application is made in ccapliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public H ealth Services. Job Address !D `�'�. City Lot Size/Acreage Owner's N:me T t Address 1 � - Phone 9-5-37 fQ � • Contractor Address OQ to o License No�� Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out or Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR Pf, OTHER ❑ Monitoring Well 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 LJ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications X-Public f-1 Other ❑ Delta Depth of Grout Seal Type of Grout , MI IrriUation Approx, Depth 0 Eastern Surface Seal Installed by Repair Work Done Type of Pump M.P. State Work Done Well Destruction 0 Well Diameter Sealing terial i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION 0 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 soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. C1 Method of Disposal Distance to nearest: Well Foundation Property Line } LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size 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 .11 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: "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 taws of California," The applicant mus or all requireq trpIpections, Complete drawing on verse side. _ Signed X Title: Date: FOR EPARTMENT USE ONLY 1 Application Accepted by Date Area I Pit or Grout Inspection by Date Final Inspection by Date 2W1 Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOVNT REMITTED CK I RECEIVED BY DATE PERMIT,NO. INFO CASH EH 13-24 INEV.i i w 51 ' EH 1