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APPLICATION FOR PERMIT t , SAN JOAQUIN COUNTY PUBLIC .HEALTH SERVICES " j ENVIRONMENTAL HEALTH DIVISION 'P O BOX 2009, STOCKTON, CA 95201 4 (2 09) 468-3447 i E R PROM 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 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and .the Rules and Regulations of San # Joaquin County Public Health Servicee. /- f { �P Job Address J �• City Lot Size/Acreage Owner's Nam f `� ddressc,, Contractor Address ' ease No Phone ` TYPE OF WEL /PUMP: NEW WELL ❑ WEkL RE PL 0. DESTRUCTION ❑ Out of Service well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r OTHER ❑ Monitoring Well C7 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 f f� Cl Industrial 0 Open Bottom ❑ Manteca s Dis..of Well Excavation Dia. of Well Casing �/ M U Domestic/Private .❑ Gravel Pack 4 D Tracy Type of Casing Specifications Cj M Public is Other ❑ pelta Depth of Grout Seal Type of Grout f yJ CI Irrigation : Approx. Depth ❑ Eastern Surface Seal Installed by v Repair Work pone U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth ' .Depth ' Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is p ' available within 200 feoLl ' Installation will serve: Residence_& Commercial_ Other r0 Number of living units: f Number ofbe'k 4dro ms '> ` Character of soil to a depth of 3 toot: Water table depth SEPTIC TANK Type/Mfg Capacity. No.,.Compartments PKG. TREATMENT PLT, 0 T � Method of Disposal � Distance to nearest: Well Foundation Property Line ' i lam' LEACHING LINE gy No. & Length of lines Total length/size a r J FILTER BED C] Distance to nearest areal: Weft ,�_ Foundation Property Lina SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well ��a�' Foundation Property Line DISPOSAL PONDS ❑ : I hereby certify that I have prepared this application and that the work wilf 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 employ any person in such manner as to becorne subject to workman's compensation laws of California." Contractor's hiring of 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." Thea licant ust call for all re d ' coons Complete drawing on r orae side. Signe Tit4e: J Dato: .. FOR TMENT USE ONLY ^7 A plication Accepted by aADate ^ ~� ^-^ ' Area i or Grout Inspection by �'" Date Final Inspection by �Dets � Additional Comments: I _ '1 Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH,DIVISION PERMIT/SERVICES 495 N SAN JOAQUIN, P '0 BOX 2009, STOCKTON, CA 88201FEE Sr-p INFO AMOUNT DUE AMOUNT REMITTED ; CASH RECEIVED BY DATE PERMIT NO. . EH 13-24(ACV.1/n!) a bO� y i EH 14.211 �� tt! .