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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX ;2009 STOCKTON CA 95201 NAY ZZ l . � � p� 0(209) 468-3447 IVA4L.J'v P I EXPIRES A � EISSUED R�fT/SC,NAVLI1 HE�7 L (Complete in Ti I Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance, with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 0 0 �E'E r - City Lot Size/Acreage ' x Owner's Name�` - �/,` mA'-� Address Phone Contract y..f Address P2&16"/Aar in--, cl- � License No. g Phone Y'23-5� � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑_/ DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION � SYSTEM REPAIR l OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL =•-OTHER WELL t PITS/SUMPS _ I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Ind trial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia, of Well Casing Zamestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public C1 Other Cl Delta Depth of Grout Seal Type of Grout _ DI Irrigation ,� Approx. Depth ❑ Eastern Surfaes Seal Installed by Repair Work Done 0 Type of Pump; ltoll� H.P. I/� LState Work Done Well Destruction 0 Well Diameter Sealing Material i Depth-< _ n t Depth Pillar Material i Depth `C1b TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION Cl DESTRUCTION M 1No sepric system permitted if public sewer is available within 200 feet.l 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 r I Capacity No. Compartments PKG. TREATMENT PLT. ❑ + '" Method of Disposal ` Distance to nearest:,.s Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line t " SEEPAGE PITS 11 Depth 1 Size Number SUMPS Ll 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, f 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 canifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mus all all requi inspections. Complete drawing on verse side'. Signed Title: Date: FQR DEPARTMENT USE ONLY Application Accepted by Date 4 �Area— Pit or Grout Inspection by Date Final Inspection by to �o Additional Comments. + Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES +ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 t FEE AMOUNT DUE AMOUNT REMITTEp CK t RECEIVED BY INFO ,L CASH PATE PPE`RMIT'NO. . EH 13.24 tREV.IrA51 FH 3�.Zd