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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOS 2009, STOCKTON* CA 96201 ,^ (209) 468-3447 s Y R ' (Complete in Triplicate) vorX in tion is is herebinma4e,liance withuganin CJpaqule Counr a ty Ordinancrmit to e No. 549struct &and 61862 and thr install eRules and eftegulationsdof San e I spplicat Joaquin County Public Health Services. SCity Lot Sita/Acreage Job Address Phone Addsr ®' Owner's Name Contractor Address License No. __ � Phone NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out M Service Nell TYPE OF WELL/PUMP. OTHER ❑ Monitoring Well 17 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ SEWER LINES ------ DISPOSAL FLO. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION � AGRICULTURE WELL OTHER WELL— OF — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia, of Well Casing fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Type of Casing Specifications U Domestic/Private Cl Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout ❑ Pub0c a -� _.I;1 Other ❑ Delta 1 M lrriparion ...._.Approx. Depth ❑ Eastern Surface Seal Installed by H P State Work Done Repair Work Done U Type of Pump Sealing Material 4 Depth Well Destruction ❑ Weil Diameter Filler Material & Depth Depth ,�(� TYPE Of SEPTIC WORK; NEW INSTALLATION REPAIRIADDITwON r_DESTRl1CTkON C1 a ailablerwthin 200leetl{led if pr'blic Sewer is v7 Installation will serve: Residence Commercial Other t Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No. Compartments SEPTIC TANK. 0 Type/Mfg Capacity V � Method of Disposal 1 PKG. TREATMENT PLT. Cl. - Property Line r Distance to nearest: Well _ Foundation — . T tal length/size- Q 6.e LEACHING LINE LI No. 8 Length of lines Property Line — ' FILTER BED la. Distance to nearest: 1NeE1 Foundation SEEPAGE PITS l I Depth Size 4 Number- LI Distance to nearest: Well Foundation Property"Line — SUMPS ,s DISPOSAL PONDS 0 I hereby certify that I neve prepared this application and that the work will be done in ac ordince with San Joaquin county ordinances, stata laws, and 01 rulesend regulations.of"the San Joaquin County not Home owner orlicensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shah ure 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, k shall employ persons subject to workniih y compenss I tion laws of California." The applicant must call for all required inspections, Complete drawing on reverse side. —23 2 r ' - Date: Signed �' Tktl@: FOR EPARTMENT USE ONLY g C� 3 Area " Application Accepted by Data Date��- Final Inspppaction by Date Pit or Grout Inspection by _ Additional Comments: J vo- Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES H ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201. FEEAMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. tNFOLl AMOVNT OtJE . EH t9-2s IRtV.+i++s� EFS 1.4.20