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> APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O SOX 2009, STOCKTON, CA 95201 �JPdescri (209) 468-3447 `�a PERMIT EMPIRES � YAR 1+`R� pATESU� 4V�(Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work hereied. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San f Joaquin County Public Health Services. �Job City Lot Size/Acreage 6D\ �� o Address /! Owner's Name LD I Lik GQGT7.c:� Address - a Phone , �• � Z� Contractor ti�0aL ��L�Add 1(o�f+'1 License No. Phone �(D-1� TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT 17 DESTRUCTION L1 Out of Service Well ❑ , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL H.D. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ! n Industrial C1 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing j fJ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications { M Public I:1 Other ❑ Delta Depth of Grout Seal Type of Grout_ -- G Irrigation —Approx. Depth ❑ Eastern Surface Seal Instailed by I� Repair Work Done U Type of Pump W.P, tat r g �1 Well Destruction [2 Wall Diameter Sealing M , Depth Filler terms i TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITIOtlr5 milted if public sewer is �nrithin 00 00f 1 ) Installation will serve: Residence— Commercial____ Other VV rk being completed Or inSPeN Number of living units: Number of bedroomsu tr inion i by vironmy :jai rleaWl,l Iter table depth +i Character of coil to a depth of 3 fest: SEPTIC TANK. ❑ Type/Mfg Capacity—. No. Compartments PKG, TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size , FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size 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 cenifies 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." Contractors 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 compsnsa- lion laws of California." ' The applicant tali for all r Tired in pactions, Complete drawing on reverse side: {�Signed Title: Date: Y R PARTMENT USE ONLY i Application Accepted by Date —.� ._ Area Pit or Grout Inspection by Date_ — Final Inspection by Date Additional Comments: — Applicant - Return all copies to: SAIF JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 FEE AMOUNT DUE RMQVN7 REMITTED �KECHVED BY DATE PERMIT NO. 3 INFO �y CA5 + EN 13'141IAEV.i ss / , �j i /U EH 14.26 !