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APPLICATION FOR PERMIT SAN JOAQUIN COUNTX PUBLIC HEALTH SERVICES ENV I RONMENTAL HEALTH DIVISIONFILECOPY P 0 BOX 2009, STOCKTON, CA 95201 19 (209) 468-3447 : M7- X 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 costpliance with San Joaquin.County.Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address z � Cit Lot Size/Acreage Sg rZ I lw; Owner'sContract Name Address Phone '-a T" NEW WELL WELL REPLAMnTYPE OFWDESTRUCTION C7 Out of Service 11e11 ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring well G7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -!�C26 DISPOSAL FLD. PROP. LINE " FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industria C1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing ;b(oomestic/Private KGravel Pack ❑ Tracy Type of Casing Specifications I3 Public [1 Oftr ❑ Delta Depth of Grout Seal Type of Grout 0 irrigation ti pprox. Depth ❑ Eas m urface Seai Installed by Repair Work Done U Type of Pump State Work Dona Well Destruction O Well Diameter , Sealing Material i Depth ' O Depth ' Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G.,(No septic system permitted it public sewer is : available within 200 feet.) Installation will serve: Residence^ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ' No. Compartments ,- PKG. TREATMENT PLT,Cl Method of Disposal Distance to nearest: Well Foundation. Property Line LEACHING LINE C1 No. b.Length of lines Total lengthtsize FILTER BED n Distance to nearest: Well Foundation: Property Line SEEPAGE PITS ii Depth Sire Number SUMPS Li Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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: "t 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 workman's compensa- tion laws of California." The applicant must 01 for all require tions. Complete drawing on reverse side. Signed x -a-r�r�L--•- Title: Date: F .ENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: — Applicant - Return all copies to: SAN"JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH AIVISION•PERMIT/SERVICES 445 N SAN JOAQUIN, P OgBOX,2009, STOCKTON. CA 95201 FEE AMOUNT DUE AMOUNT REMiTTEO I CK RECEIVED BY DATE PERMIT NO, MINFO `, r CASHG . CH 13-24414EV.tiat �`�S 00 ys.� 10 1.8 � 1 �� X13`71♦ EM,x•26 .