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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION j 445 N SAN JOAQUIN, PHONE (209)468-3420 t P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FRPM DATE ISSUED ' . (Complete in Triplicate) 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. 51+4 and 1862 and the Rules and Regulations of San Joaquin County Public/Health Services. Job Addressc/ W ^&,L�, City Lot Size/Acreage d Owner's Name �rf � M1, ✓ Address �Ca l n� ° p ^,sg Phone 6 67 1 i Contractor _ / Address License No. Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 Ll Industrial fJ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing fl Domestic/Private Cl Gravel Pack7 ❑ Tracy Type of Casing_. Specifications \ r I"I Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Wall Destruction O Well Diameter sealing Material i Depth Depth tiller Material li Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTIONXI INo septic system permitted if public sewer is 11 / available within 200 feet.! I ins ion will serve: Residence Commercial_ Other Number of Number of bedrooms Character of aoil to a of 3 feet: � Water table depth SEPTIC TANK ❑ Type 1Gspac y No. Compartments PKG. TREATMENT PLT.❑ '� Method of Disposal Distance to nearest: W Foundation Property Line LEACHING LINE C1 No. a LB of lines Total length/silo FILTER BED ❑ nce to nearest: Well Foundation Property Line SEEP�PITSl1 Depth Sire Number SUMPLI Distance to nearest: Wail Foundation Property Line ! SAL 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 i Horne 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: "l certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- t tion laws of California." The applicantst call for al!required i apections. Complete drawing on reverse side. �. t/ Signed Title: �rii� {C Date: � R DEPARTMENT USE ONLY Application Accepted by �' Date 3 Area Pit or Grout Inspection by Date Final Inspection bw Date Additional Comments.- Applicant omments:Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 495 N San Joaquin, p 0 Boa 2009, 8tko, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATY PERMiT•NO. INFO . EHI3-21(REV.Fiw6F .5 ' EH t4•2a f