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APPLICATION FOR PERMIT 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468--3,4V 3qaO PERMIT R PRQM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aztd Regulations of Saar Joaquin County Public Health Services. rr,- f r �- C_ � Cit "tempt Lot Size/Acreage/a0 Job Address Y-.. Owner's Name + -- Address u Phone 36(F ~� Contractor n Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well t ❑ PUMP INSTALLATION F) SYSTEM REPAIR OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f.] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/private ❑ Gravel Pack D Tracy Type of Casing Specifications M Public CI Other ❑ Delta Depth of Grout Seal Type of Grout C1 IrriUaI' Approx. Depth ""�;; ❑ Eastern Su ac Sat Installed by ,Done rpe of Pump y _ H.P. -- f -r - _State Work Done-_ Well Destruction ell Diameter Sealing terial i Depth Depth r F111er.Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 ,REPAIR/ADDITION Cl DESTRUCTION 0 (No septic system peimitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial. Othei f Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT, 0 _ Method of Disposal Distance to nearest: Well Foundation Property Lina I LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED f-7 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth _ _ _ Sixe Number SUMPS LI bistrtince to nearest: Well Foundation Property Line DISPOSAL PONDS © F 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 not i 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: "l 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 ust cell for r ired inspections, Complete drawing reverse side: iv- % �3! Signed Title: Date: r R DEPA ENT USE ONLY rf Application Accepted by Date _ t , Araa 1 A �Pit or Grout Inspection by ___ __ Gate Fina! Inspection by ---- Date Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH V SION PERMIT/SERVICES ^ 445 N SAN JOAQUI O OX 2009, STOCKTON, CA 95201 FEE 11 INFO AMOUNT OtJE AMOVNT RE ITTED CASH RECEIVEl3 8Y UATE PERMIT NO. . EH 13-24(REV.1 $1 ® t:H A.2!