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APPLICATION FOR PERMIT ILI) SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES / ENVIRONMENTAL HEALTH DIVISION r/ P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 YEAR PROM DATE ISSUED (Complete in Triplicate) Application is hereby Stade to San Joaquin County for a permit to construct and/or instsll 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 Sen Joaquin County Public Health Services. Job Address 9S K-5 �� City Lot Size/Acreage Owner's Name �'�Z 'Address _.., _ Phone Contra ddres � i -�- rSJy1 License N�� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR � OTHER ❑ Monitoring Well C1 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 n Ind ua vial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omastic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications M Public f7 Other ❑ Delta Depth of Grout Seal Type of Grout G Irrigation Approx. Depth ❑ Eastern /Surface Seal Installed by Repair Work Done 0o Type of Pump --&-t H.P. �� Stats Work Done Well Destruction O Well Diameter Sealing Material i Depth D(] Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION M DESTRUCTION G (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 - L Character of soil to a depth of 3 feet: Watept&YACNT SEPTIC TANK ❑ T yp./MiQ +� Capacity - No. P _, PKG. TREATMENT PLT. ❑ Metl�gd ff QitOsaFt Distance to nearest: Well Foundation Property Line'+ SAN JOAQUIN CO 1.1; LEACHING LINE Cl No. 8 Length of lines Total Ienih�} �'� - v � FILTER BED 1=1 Distance to nearest: Well Foundation roperty ins , 1'1 SEEPAGE PITS I I Depth Sire Number SUMPS Li Distance to nearest: . Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that f have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, state laws, and "(ules and regulations of the San Joaquin County Home owner or licensed agent's signature cartifies the following: 1-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 Jaws 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 laws of California." E The applicant mu ell required inspeG ions. Complete drawingverse side. Signed Title: Date: FOR DEPARTMENT USE ONLYAV 17 L Application Accepted by Dare Area w �� Pit or Grout Inspection by Date Final Inspection W Dale 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 95201 y/IFEE EFO )'A+MO^U/NyT�DUE AMOUNT REMr7150 CASH RECEIVED fly 7 nDATE PERMIIT]'NO. . EH 1`- 1REV.11My1 -�U�7� 1 r� —�G 6�