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APPLICATION FOR PERMIT j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STWKTON, CA 95201 ` (209) 468-3447 (V L R � A t� (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 Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San In County Public Healt Services. Job Address City Lot Size/Acreage Owner's Name Address kill/ Phone Contractor ;; •; Address License No. Phone d TYPE OF WELL/PUMP: NEW WELL 13 WELL EPLACEMENT C7 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION 0 SYSTEm REPAIR 0 OT -R-❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES __ OISP ,-- PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE NSTRUCTION SPECIFICATIONS f_1 Industrial ❑ Open Bottom la M a Dia, of Well Excavation Dia. of Well Casing L) Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications M Public 1.1 Othe ❑ Delta Depth of Grout Seal Type of Grout G irrigation .._._.Approx, Depth ❑ Eastern Surface Sed) Installed by Repair Work Do Type of Pump H.P. State Work Oona _ Well Des tion CO) Well Diameter Sealing Material i Depth Depth ""Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION.0 REPAIR/ADDITION 0 DESTRUCTI 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 ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT, 0 Method of Disposal i Distance to nearest: Well Foundation Property Line . 1 LEACHING LINE C1 No. 8 Length of lines Total Iength/sire FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 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 taws of Cafifornia." The applic t must call for all a in tiRms, Camplate drawing reverse side L'"L grf/�i� , Signed Title. Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by�' Date Additional Comments; Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2049, STOCKTON, CA 95201 FEE INTO A OUNT DUE AMOUNT REMITTED -ZACSN RECEIVED BY DATE PERMIT'NOEN 13-24 MEV. V , �y 9 "� CH'4.X �.7