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i f 'k APPLICATION FOR PERMITR SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES KECEID ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 SEP 3 0 1992 (209) 468-3447 . ENVIRONMENTAL HEALTH R ORQM PAJE 10UN), PERM9T/SRViCE� (Complete in Triplicate) Application is hereby made,to San Joaquin County for s 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 Services. a Job Address12� City of Size/Acreage Owner's Name Address Phone r Addre Contract ��'� � s� TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well [1 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 CI Ind trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ❑ Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout G Irrigalion Approx. Depth l❑ Eastern Surface Seal Installed by Repair Work Done &-- Type of Pump WP, Crll� State Work Done _ Well Destruction O Well Diameter Sealing Material Z Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIAIADDITION 0 DESTRUCTION G INo septic system pwmitled if public sewer is available within 200 feet.] 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. ❑ ,; Method of Disposal i # Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS- 11 Depth Size Number SUMPS Ul Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I haieby 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 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- lion laws of California." The applicant r all require4 in"ctions. Complete drawing on reverse side. Signed Title; +t-/ - Date: FOR DEPARTMENT USE ONLY Application Accepted by C004A.4 , Date tJ� ��! Ar Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P OJOAR400$, STUCKTDN, CA 85201 INFO AMOUNT DUE � A DUN7 REMITTED CK REGI 0 BY DATE PERMIT NO. r EH 13.24 IREY.