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APPLY CATI ON FOR PERMIT S SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 YEAR FM DAT&II&M (Complete in Triplicate) Application In hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compllance with San Joaquin County,Ordinance No. 51x9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage "' ,t KOwner's Name6 Address 2 11__`5117 S7-- Phone p>CA)i -,e)` e--,A 93o3o Contractor Address `'—� License No. Phone TYPE OF WELL/PUMP, NEW WELL,❑. _. WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well L DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca bia. of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack C3 Tracy Type 6f Casing Specifications - M Public lel Other p Delta Depth7o! Grout Seal Type of Grout 4 G Imoation Approx. Depth ❑ Eastern Surface Seal Installed by 1 II Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth `� I 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.) i Installation will serve: Residence ZCommercisl_ Other Number of living unite: Number of bedrooms .— Character of soil to■ depot of 3 feel: I=Vc5wlter table depth SEPTIC TANK Q Type/MfgF. -rl E V I LICOPLMAW. Compartments PKG. TREATMENT PLT, ❑ {� Method of Disposal Distance to nearest: WePermi m uOdYgnexpGred Vd4 0 rty Line ' LEACHING LINE ❑ No. & Length of lines FILTER BED n Distance to nearest: We oundatron Property Line SEEPAGE PITS 11 Depth Sire Number i 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 certifies the following:'"I certify that in the peHormance 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 Calilornia." Contractor's hiring or subcontracting signature candies 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 must call for all required inspections. Complete drawing on reverse side. Signed Title: JI,k0R DEPARTMENT USE ONLY I � Application Accepted by Date =21:n Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 135201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY { DATE PERMIT NO. r EH 13.21 tnEV.10%so ti} ! �0 t UQ 1P- `�, {H 71.26 +! ` 1