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APPLICATION FOR PERMIT S SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201. r D J� (209) 468-3447 PERMIT EXPIRES 1, YEAR EM„BATT ISSUED (Complete in Triplicate) Application is hereby rade 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 Sery es. lob Address _ u City Lot Size/Acreage KOwner's Name Address Phone a79 �o2 Contractor^ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service'Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [7 DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications M Public f l Other © Delta Depth ot.Grout Seal Type of Grout G Irrigation _.Approx. Depth © Eastern Surface Seat 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 1 REPAIR/ADDITION L1 DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of diving units: Number of bedrooms Character of $oil 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 Line LEACHING LINE 0 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 ❑ I hereby canify 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 .1 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 subcontracting 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 workmen's compensa- tion laws of California.,, The applicant must tail re fired insPections. Complete drawing on reverse side. r KSigntdTWO: Date: FO PARTMENT USE ONLY Application Accepted by _. &e „�, }�„ Date "4z> Area Pit or Grout Inspection by Date Final Inspection by5_ (&=- Date f� Additional Comments: 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 AMOUNT DUE AMOUNT FIEMITTEO S AECEIVED BY DATE PERMIT NO. INFO EN 114-28 + EH 13.24 IR EV.1in5) (� �` //