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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES '. ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 ('209). 468-3447 1pTRA�TT.UPIRES 1 YEAR )DRQ DAJR ISO ! (Complete in Triplicate) Application is hereby made,to San Joaquin'County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joe uin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public7 th Se-5 41u ow City Lot Size/Acreagef�p -y-Job Address j/ r� //!J,! �jf� r+ry 5/(J lk L/rJ t� r{ C V r/ V/ 1� � One ` /-7— 7 Y r Owner's Name Address I / I Contractor e, Address �� License No. Phone - TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP TION ❑ SYSTEM REPAIR C1 OTHER ❑ itoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 'DISPOSAL FLD. OP. LINE FOUNDATION CULTURE WELL OTHER WELL PITS/SUMPS Y_ S INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPEC kONS ° L1 Industrial ❑ Open Bottom ❑ Manteca Dia. a II non Dia. of Wel! Casing U Domestic/Private C1 Grave! Pack; C7 Tracy f Ty asin Specifications ' M Public f 1 Other ❑ Delta Depth of Grout Sea Type of Grout M Irrigation _,Approx. Depth ❑ E Surface Sedl Installad by y Repair Work Done. U Type of Pump H.P. State Wor ne \ Watt Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material'i'Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION (No septic system permitted if 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 Cl Type/Mfg Capacity ,, __ No. Compartments PKG. TREATMENT PLT, 0 : Method of Disposal Distance to nearest: Well Foundation. Property Line LEACHING LINE Cl 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, a 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 shallnot = 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 this performance of the work for which this permit is issued, I shall employ persons subject to workmen's compensa- k lion laws of California." l The applicant t call for alt r ui Inspections, Complete dra in n reverse side' �f i 0 ^Signed �'" i ' '� ��. Date: FO EPART T USE ONLY Application Accepted by Date Area i 2 Pit or Grout Inspection by Date Final Inspection by ate Additional Comments: r Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES r. 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 ` FEE AMOUNT DUE AMOUNT REMITTED CK rRECEIVEO BY DATE PERMIT'NO, INF CASH . EH 13-24(REV.t�w51 24,0� 1�� EH 31.2! GG