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APPLICATION FOR PERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIS �"j`C r f ENVIRONMENTAL HEALTH DIVISION k P O BOX 2009, STOCKTON, CA 95201 � w (209) 468-3447 _1! t IT ESDI ES I YEAR (Complete in Triplicate) Application is hereby made to Sari 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 and Regulations of San Joaquin County public Health S vices. Job Address City Lott,B} /Acreage c.!`f g��v79 Owner's Name ddress �� hone n factor dre 1 License N Phone/ TYPE OF WELL/PUMP. NE ELL�L7 WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION 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 n ndustrial ❑ Open Bottom ❑ Manteca '— Dia, of Well Excavation Dia. of WeN Casing i Bcrmestic/Private ❑ Gravel Pack ❑ Tracy ti� Type of Casing Specifications M Public 11 Other r so Delta Depth of Grout Seal - Type of Grout i Cl Irrigation Approx. Oep h Eastern Surface Seal Installed I �j, Rap Work Done U Type of Pump,4d_ - H,P. f to D n l Wall Destruction O Well Diameter Sealing Xiterial i Depth r Depth F.111er Material it Depth I' TYPE OF SEPTIC WORK: NEWINSTALLATION 0 .REPAIR/ADOITION CC DESTRUCTION G INo septic system permitted if public sewer is J Y" available within 200 feet.) Installation will serve: ResidenceJ! Commercial_ Other I Number of living units: Number of bedrooms 2 r Character of soil to a depth of 3.faer Water table depth SEPTIC TANK ❑ Type/Mfp Capacity No. Compartments € PKG. TREATMENT PLT.Cl Method of Disposal ' Distance to nearest: Well Foundation Property Line E LEACHING LINE ❑ No. ill Length of lines Total length/size FILTER BED n Distance to noarest`.`� Well Foundation Property line SEEPAGE PITS I I Depth Sire Number SUMPS ll Distance.to nearest: Well foundation Property Line 4v. DISPOSAL PONDS ❑ I hereby comity 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: 1 comity that in the performance of the work for which this permit is issued, I shall not 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 compensa- tion laws of California." The applic&W49st call fo �ra4,1n".etions. Complete drawing on r ►se side. Sig !>"✓ Titf Date: FOR DEPARTMENT USE ONLY i Application Accepted by Date �r Area ;z Pit or Grout Inspection by Date Final Inspection by��/Gr� Date Additional Comments: — Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y , ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 I FEE � INFO AMOUNT DUE 'A�M�OU�NTRE+MITTED CS'H/� DECEIVED (3Y DATE PERMIT'NO. . EH 13•24 tREV.Ii86s - t'H;42a i