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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROMIENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 r :{ PERM T EXPIRES 1 YEAR FROM DATE S t r (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 in made in cowliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services /�� Job Address �36 / City hot 81 se/Acreage r Owner's Na Address '� Phone PP�,__ LU t� . z ContractoY`'�",� � Address r License N� Phone TYPE OF ELL/ UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑. -SYSTEM-REPAIR ❑- OTHER-0 .ldonitoring Well ❑ a DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r/,� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private Ci Gravel Pack 0 Tracy Type of Casing_ Specifications V] Public Ci Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done bliate Well Destruction ❑ Well Diameter i sealingrial tr Depth Plft Depth j biller Naterial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRYADDITION DESTRUCTION I I INo septic system permitted if public sewer is Vti available within 200 feet.l �•� Installation will serve: Residence J Commercial_ Other " } Number of living units: —/— Number of begkoorrs / ;.f �t Character of son to a depth of 3 feet: Water table depth 4' SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal Distance to nearest: Well Foundation Property Line rt. . 6X LEACHING LINE JJ[ No. b Length.of lines Total length/sea FILTER BED O Distance to nearest: Wdllkk Foundation Property Line r ..�' w 1 / SEEPAGE PITS I I_-,-Depth - -- Size PYo- - — ,Nujrtbar-- f SUMPS Distance to.rtearast: Well f Foundation 147 / Property Line S DISPOSAL PONDS ❑ j s 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contrectoes hieing or sub-contracting signature f certifies the following: "I certify that in the performance of the work for which this permit is issued,I Phan employ persons subjecf to workman's compensa- tion laws of California." i The appliCan at Call for fired inspections. Complete drawing on reverse sid . p 1r� Signed Title: \ —.____ Date: ----- — �- )ed fOR-DEPARTMENT USE ONLYApplication Accapby s Date 7 � Area & . Pit or Grout Inspection byDate Final Inspection by Data _ Additional Comments: . Applicant - Return all copies to: San Joaquin County Public Health Services ` Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED Ck K RECEIVED BY DATE PERMIT'NO. k INFO . EMM24IREV.r/A5) EH HIM