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r APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SHRVICHS �' i r ENVIRONMENTAL HEALTH DIVISION gr h'.. Z P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 Ei� �AY 2 "MIT EXPIRES Y YZAR PROM 12ATE �� , t'RoN r (Complete in Triplicate) RV��E H Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein describe This application is made in compliance vith San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public 4.th.8erar1res. Jab Address G� City tot size/Acreage Owner's Name Address PaF '`fir°C Phone Contracts Address icense No. �s.Z-- Phone ��- 1 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cn DESTRUCTION ❑ Out of Service Well C1 PUMP INSTALLATION ❑ SYSTEM REPAIR � 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 PR09LEM-AREA., CONSTRUCTION SPECIFICATIONS N fl Industrial ❑ Open Bottom ❑ Manteca Dia.,of Well Excavation Dia. of Well Casing N omasticlPnvate ❑ Gravel Pack ❑ Tracy. ,,,,Type of Casing Q Public Specifications I'll Other 0 Delia' . e th of Grout Seal Type of Grout CJ 1niUation Approx. Depth ❑ EasternI Surface Saul Installed by Repair Work Done . U Type of Pump H.P. _� State Work Done Well Destruction ❑ Well Diameter Seallrig Material,i_Depth id"dd Depth biller Material 4 Depth �- TIT SEPTIC WORK; NEW INSTALLATION.0 REPAIR/ADDITION M DESTRUCTION G (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth t SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal C 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 s DISPOSAL PONDS ❑ " , t I hereby certify that I have prepared this application and that the-work will be done in eccordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County 3 Home owner or licensed agent's signature cenifies the foflowing; "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 laws of California." The applicant must call fo&quired fspsctionsrComplete drawing on versa side. Signed Title: r i x Date: NR DEPARTMENT USE ONLY Application Accepted by Date Area _L`� /I Pit or Grout Inspection by Date Final Inspection'. Date / Additional Comments: - Applicant » Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 1 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT RENCTCK TED INFO RECEIVED BY DATE PERMIT NO. CASH EH 13,24 IREV. EH-,.Ze /e i! r! rI /yds ^� i r��