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APPLICATION' FOR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ' P O BOX 2009, STOCKTON, CA 95201 i PERMIT EXEIRABS I YEAR EROM DATE IS§UED , (Complete in Triplicate) Application is hereby made to San Joaquin Count for permit to construct and/or install the work herein described. This application is made in campq y s liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Pfblic Health Services, Job Address City Lot Size/Acreage O ner's Name ress Phone 1 i C tra- ctori��V ress License Phone� �"��1�/ TYPE OF WELL/PUMP: NEW Wtq ❑ WELL REPLACEM NT ❑ DESTRUCTION Ll Out of Service well ❑ PUMP INSTALLATIONX— SYSTEM REPAIR 0 OTHER ❑ Monitoring Well 0 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 `Cl Industrial ❑ Open Bottom 11 Manteca Dis. of Well Excavation Dia. of Well Casing � 'r HnesticlPrivate ❑ Gravel Pack 0 Tracy Type of Casing— Specifications. 11 Piblic 1:1 Other n Delta Depth of Grout Seal Type of Grout I I Irfigation —.Approx. Dept ern �� rface Seal Installed by Repair Work Done U Type of Pump I ! stH.P. State Work Done Well Destruction O Wel! Dia er Sealing Material L Depth Depth T Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION LI INo septic system permitted if public sewer is _ j.. available within 200 feet.) Installation will serve: Reside-—'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.Cl _ Method of Disposal Distance to nearest: Well Foundation Property Line {t�1 LEACHING LINE CI No. S Length of linea Total length/size k FILTER SED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS t 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDSi 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 regulation's of the Sen 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�n such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the followin�gg: "1 c rtify that in the performance Of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- 1 tion laws f forriL k The spells 't to f In tions. Complete drawing on r roe aid l Sp Title: Date: i ep 1 DEPARTMENT USE ONLY -- Application Act ted by (�.�_ Date 2 Area Pk or Grout Inspection by Date Final Inspection by Date II lI f Additional Commints: Applicant - return all copies to: San Joaquin County Public Health Services # Environmental Health Permit/Services 445 N San Joaquin, P O Box 2005, Stkn, CA 95201 FEE AMOUNT�[�` DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'N0. EN 1344• EN1�galltEV.E/n51 �Q /JrabJ� r`� vj