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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servic a. Job Address --/ / � L-t-1 �! City '.`/v Lot Size/Acreage Owner's Name �" Address Phone Contractor <(� Address a / �"j Lf �e No. YS�d Iv Photr �TV%7 TYPE OF WELL/PUMP: NEW WELL C1WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D Monitoring Well C7 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 D Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing r.1 Domestic/Private Cl Gravel Pack O Tracy Type of Casing_. Specifications I'I Public 11 Other n Delta Depth of Grout Seal Type of Grout 11 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction D Well Diameter Sealing Material i Depth Depth Tiller Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRU�TI.ON 11 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. b Length of tines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth SizeNumber � f/QQ SUMPS LI Distance to n�ea�prestp Well d Foundation—��7n Property Line DISPOSAL PONDS ❑ /� / �'1 3 Q / :3 6 / e�P I hereby certify that 1 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, 1 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: 111 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 ap X=all for ed '� ctrons. om a drawing on reverse side. Signed X �� Title: l Date: l FOR DEPARTMENT USE ONLY A lication Accepted by Date r Area / ir ��U � Date Final Inspection by � / �� Date — or rout Inspection by 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 RECEIVED By DATE PERMIT NO. IN O . EH 13.14(REV.rixsr / �. EH 11-2a / G