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APPLICATION FOR PERMIT .t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I' P 0 BOX 2009, STOCKTON, CA 95201AY 9 (209) 468-3447 PERMIT EXPIRES 1 YEAR DAI ISSUED ERM1 f frTAL HEALTH I. (Complete in Triplicate) PERM1T1SC>4Ufr ES 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 Services. 0. Job Address X0 it City�� _ Lot Size/Acreage Owner's Name _ Address Phone f f Contractor . Addressfe—D&& L-� %: 30�.License No. 2, Phone -x:v TYPE OF WELL/PUMP: NEW WELL ❑— / WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION Ids SYSTEM REPAIR 41OTHER ❑ Monitoring Well L� 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 n Industrial O Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing omestic/Private 0 Gravel Pack ❑ Tracy - Type of Casing Specifications M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout G Irrigation Approx, Depth ❑ Eastern t Surface Seal Installed by Repair Work Done Type of Pump .ar4r?'= H.P. t�Y� ' State Work.Done Well Destruction O Wail Diameter Sealing Material 4 Depth- DepW Filler Material 6"Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION C1—DESTRUCTION G (No septic system permitted H public sewer is available within 200 feetJ Installation will serve: Residence — Commercial Other Number of living units: Number of bedrooms t Character of soil to a depth of'3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg �. ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal i Distance to nearest: Welt Foundation Property Line 1+ LEACHING LINE 0 No. & Length of lines % Total length/size j 'FILTER BED ❑ Distance to nearest: Welt Foundation Property Line I SEEPAGE PITS 11 Depth Sire / Number T" SUMPS 0 Distance to nearest: Well # Foundation Property Line W DISPOSAL PONDS ❑ i. { I hereby certify that I have prepared this application and that the woik 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 sub-contracting 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 mu c I for all requir d inspections, Complete drawing on reverse side. Signed A Titie: Date: FOR DEPARTMENT USE ONLY Application Accepted by Dates Area Pit or Grout Inspection by 1 Date Final Inspection by ate 4 ,a Additional Comments, Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT-REMITTED ♦ CK RECEIVED 8Y DATE PERMIY'N0. INFO ]� CASH . tH 13.24IREV.I/N51 IL EH 1426 W/