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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES s,/ ENVIRONMENTAL HEALTH DIVISION � p O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 Y R (Complete in Triplicate) in Application is hlaadebincocompliance vSan ithuBan County Joaquinfor County Ordinanceconstruct flo. 549and/or 1862install and thethe Rules andhere Regulationsdof Sans aypl i Joaquin County Public Health SeryAciii GL ew-5;5 Cit S Lot Size/Acreage Job Address I Phone Owner's Name r M Am r Address pp License No. :ic essConNaclor pESTRUCT10N ❑ Out of See well Cl TYPE IF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT C] Monitoring well El PUMP INSTALLATION Q SYSTEM REPAIR C7 OTHER ❑ SEWER LINES DISPOSAL FLD. PROP. LENE , DISTANCE TO NEAREST: SEPTIC TANK , �r---- AGRICULTURE WELL OTHER WELL SUMPS I FOUNDATION f TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS INTENDED USE �...�--•---�— Dia. of Well Casing a ❑ Open Bottom ❑ Manteca Die. of Well Excavation ❑ Industrial Specifications—== G Domestic/Private D Gravel Peck ❑ Tracy Type of CasingDepth of Grout Seal Type of Grout M Public f-1 Other ❑ Delta CJ Irrigation Approx, Depth 0 Eastern Surface Seal Installed by H P State Work Dona Repair Work Done L3 Type of Pump --- Sealing Material Depth Well Destruction D Well Diameter -- Filler Material i Depth Depth permitted if public sewer is m er t I I No septic aYste p [ TRUCTION G R P f TYPE OF SEPTIC WORK: NEW 114S till, Cl REPAIR available within 200 1861.1 Installation will serve: Res' once�l Commercial, Other Number�of living units,," ' Num of bedrooms Water table depth , Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK . ❑ Type/Mfg GaPacity— s Method of DispOsa I PKG. TREATMENT PLT. 0 'I f .t Foundation .5 Property Line � Distance to naarest:._....,Wellz:60 - y. Total tength/size LEACHING LINE ❑ No. A Length of lines property Line E FILTER BED ❑ Distance to nearest:` ' Well.— Foundation s r . d.. Size l fJumber SEEPAGE PITS 11 Depth Property Line SUMPS ll Distance to nearest: Well Foundation D19POSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance Nh h San Joaquin county ordinances, stats laws, and rules and regulations of the San Joaquin County � ollowing: "I certify that in the performance af'the work for which this permit is iss Home owner or licensed agent's signature certifies the fued, i shall not to workman's compensation laws of California." Contractor's hiring or sub-contracting signature* employ any person in such manner n to become subject certifies the following: "1 certify that in the performance of the work for which this permit is issued. I sI ll employ parsons subject to workman's compensa• l tion laws of California." i let drawing on verse side The ap licant call or a req ed in ch' -s g f s r 9 t Title: Date: Sign r I FOR DEPARTMENT USE ONLY f } 1 li Date Ares Application Accepted by -�-�- --- 16 [ S� Date 1 Pit or Grout Inspection by Date -- Final Inspection by i — Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES —ENVI-RONMENTAL.HEALTH-DI-VISION-PERHI-T/-SERVICES ICES -^ '"' 445 N SAN JOAQUIN p O. BO% 2009 STUCKTON,"CA 95201 4 CK RECEIVED BY DATE PERMIT'N0. FEE AMOUNT DUE AMDUNT REMiTTED.r CASH _ INFO . EK 13-74(REV.I/x5) l EK'476