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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES R E C' V u ENVIRONMENTAL HEALTH DIVISION NOV 5 1990 P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH (209) 468-3447 PER MIT/SERVVES PERMIT EXPIRES I R FM DATE SSUED (Complete in Triplicate) Application is hereby sada to San Joaquin County for a permit to construct and/or install the vork herein described. This ma application is de 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 a City of Sime/Acreage Owner's Name Address __ Phone Contractor Address o 30 License No Phone , TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Ci DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well 0 - 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 171 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications M Public I'1 Other ❑ Delta Depth of Grout Seal Type of Grout CJ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done Type of Pump V H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/AOOITION 0 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_-Other Number of living units: Number of bedrooms _ Character of toil to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. 0 r Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sira Number " -SUMPS L1 }Distance to nearest: Wein — ` Foundation — "Props"-Line �- DISPOSAL PONDS ❑ 1 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." 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 callA r all required i s ctions, Complete drawing on reverse side. t 4 P4 g r� Signed X G Title: Dater - FOR DEPARTMENT USE ONLY Application Accepted by Date �JF 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 DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE J� PERM117'N�OO. . EH 13-24 tREv.liner EH:626