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.j,.. APPLICATION FOR PERMIT r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �O ply ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i PFMIT TS ] YFIAR FROM DTE USUED (Complete in Triplicate) Application ie hereby made,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 Ifo. 549 and 1662 and the Rules and Regulations of Ban Joaquin County Public Health Services. Job(Address City Lot Sire/Acreage ! ` a Name Address Phone �~ C r or " "� aAl) can o. 9 Phone -2612J,i TYPE OF WELL/PUMP: NEW WELL OU WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Yell ❑ k 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 I 0 Industrial ❑ Open Bonom ❑ Manteca Dia. of Well Excavation VA. of WON Casing 1-1 Dornestie/Privele ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i 1'1 Public n Other ' n Delta I Grout Seal Type of Grout Xk;Ii ation —.ApproH. Depth I I Eastern Enlists ,at Installed by 1 f� Raptiir Work Done ❑ Type of rump l- State Work Dons . We/Destruction ❑ Well Diameter =7m�.-tr Lal A Depth Depth !1eial A Depth �i _oL TYPE( OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIA_DDITION I towe I DESTRUCTION l 1 (No septic system permitted if public r is - - . available within 200 fact.). V 5 Ins taflation wRI serve: Residence— Commercial_ Other 1 Number of Bring units: Number of bedrooms ' T Character of soft to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity- C3mpanments d PKG.TREATMENT PLT.❑ Method of_Disposal Distance to nearest. Well Foundation ._ _ r �� Property Line f a1 1 LEACHING LINE ❑ No. a Length of lines Total length/size FILTER BED ❑ Distance to nearest. -wall 1•.* "`_ Fouhdation Property Line SEEPAGE PITS I I Depth Size 1�`; Number SUMPS LI Distance to nearest: Well Foundation Property Lina O ' 61SPOSAL PONDS ❑ I haiaby certify Thal I he"prepared this application and that the work will be done in accardancs with San Joaquin county ordinances, state Laws, and rules land rrguiations of the San Joaquin County Homo owner or licensed agent's signature certifies the following: '9 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-qr sub•coniracting signature certifies the folowinp:"I certify that in the performance of the work for whkh this permit is issued,I shall employ persons subject to workmen's compensa- tion laws of California." The eppCica I r N rd. Complete drawing on ve "ids. ✓' r Sig n+ d tie Dater FOR DEPARTMENT USE ONLY Application Accepted by Date �`-F Area Pit or Grout Inspection by Date / Final inspection by Data / Addhior►el Comments: fz . `�LL I Applicant - Return all copiee to: San Joaquin County Public Health Services o VTC• Suvirontnental Health PermitlServices t 445 N San':Toaqufb. P'O Aox 2009, Stkn;.•CA 95201- CK 8 IN/F�O AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERIMITNO. • EH'M24'1119V:tlr61'� EH t/.30