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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENNTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PFMIT EMIRES 1 YEAR FRQM DATE S (Complete in Triplicate) Application is hereby made to Elan Joaquin County for a permit to construct and/or install the work herein described. This application is made in cc4liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health ServiceT Job Address _7❑ s. , r, � ' _ - City eo Lot Size/Acreage Owner's Name LLQ-�`c t d" Address L Phone 66F-f Contractor Address v l< License N37�3FS Phone 73,/- y� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTAUCTION)iIcOut of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 0 Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications I'1 Public Cl Other i-1 Delta Depth of Grout Seal Type of Grout I I Irrigation 3 J Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. Stat*_Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth CWrtc Depth 3 o Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet) Installation will some: Residence_____ Commercial v Other Number of living units: Number of bedrooms Character of sod to a depth of 3 fest: Water table depth SEPTIC TANK. ❑ Typs/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line 711 LEACHING LINE Cl No. E Length of lines Total length/size- -FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L1 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 performance of the work for which this permit is issued. I shall no 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 compenss- tion laws of California." The applicant must II for requir inspgctions. Complete drawing on reverse� Ile-e-side. 9. G �+ Signed /Lti" Title: _ � _._._ Date: 'a l F:::TEPARTMENT USE ONLY Applicatlon Accepted by �&,,, aA�M�_pm, ah Date Z--� Area Pit or Grout Inspection by p 1 Date Final Inspection by Date 1Q--6^rig Additional Comments: D� r iT L � Cis r t �c Iic, �, { Applicant - Return all copies to: San Joaquin County Public Health Servicesl_.//^^a�j � a EnvironmentalHealth Permit/Services 4 4455N N SanSan Joaquin, P O cox 2009, Stkn, GA 95201 oFEE INFO AMOUNT DUE AMOUNT REMITTED C V g RECEIVED BY DATE PERMIT'NO, [ytJ � � Sucf4 . E1YI4(REV.tiX41 � r O ✓ `/L Q/�y �� EMN 1sjQa ! / !�