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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 i HERMIT EXPIRES 1-YEAR-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 is made in conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.® Job Address /� '� �1 City -a i Lot Size/Acreage 1 t� e, €- Owner's Name ddress ( -_ j1['_ !`i i1__�'-*15_ Phone � � Contractor I r re Address f�� r)�r° �c3- /� License Notes=i„i.r „ Phoneme ` �-aJ TYPE OF WELL/PUMP: NEW WELL d WELL. REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well Ll PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring }sell O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE /—S- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS In ustrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation pia. of Well Casing D msatic/Private XGrovel Pack 0 Tracy Type of Casing srC Specifications' ublic Cl Other ❑ Delta Depth of Grout Seal r Type of Grout - �/ r Ct Irrigation `T 0(_,Approx, Depth ❑ Eastern S ace Seal Installed by I, life 11.111 n K. Repair Work Done !; a Type.of Pump H.P. State Work Done ' Well Destruction ❑ Well Diameter Sealing Material i Depth (1 ` Depth Filler Material i Depth TYPE OF-SEPTIC,WORK:. NEW INSTALLATION❑ REPAIRIADOITION 0 DESTRUCTION G INo septic system permitted if pubfic sewer is r� 'a. available within 200 feet.) l✓ 1 _.4 Installation will serve: Residence 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, 0 Method of Disposal ~- Distance to nearest: Well Foundation Property Line F:. _ l `LEACHING LINE. L`I No..r Length of lines Total length/size FfLTER BED ""n Distance to nearest: Well Foundation Property Line _ 7 ISEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ . ;I heretiy'certify that t have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner of 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 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 applicant must call for all required inspections, Complete drawing on reverse side. Signed Title: Date: FOR DEPARTMENT USE NLY Application Accepted by `�� Date �—a 7--Q t Area 1 Z Pit Gron nstxction by, y- Date L:2�� 4 f Final Inspection by�. Date 2Z �� + Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 995 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 e INEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. S! 0ILe w R�� • EM 17.211ReV.i/ni tg/ E++14•26 3D-0 r� -a2