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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION t P O BOX 2009,10 STOCBTON, CA 95201 No (209) 468-3447 i4n" PERMIT EXPIRES 1 YEAR PROM DATE ISSUED Na &k (Complete in Triplicate) `�` M , Alication to hereby made to San Joaquin County for a permit to construct and/or install the work h ein described. This pplicatioa ie made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 7� Job Address ,, y S ^,�, ��Z� _ City�LWr2Lot Size/Acreage Owner's Name � 1 '1`' r"f" } wgAddress rTg2 ,fie > � �a r -- Phone V N IF?_ Contractor Address 45��+' J¢yl License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 f_l Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing CJ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public I'll Other ❑ Delta Depth of Grout Seal Type of Grout Ci Irrigation Approx, Depth ❑ Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _. Wall Destruction 0 Well Diameter Sealing Material k Depth Depth Filler )Material L Depth TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION 1:1 INo septic system permitted 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 �n SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS 11 Depth Size Number SUMPS LI 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, 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 MUNI call for all required i no. Complete drawing on reverse side. Signed k.. Title: Date: F DEPARTMENT USE. ONLY Application Accepted by ` �-- Date Area Pit or Grout Inspection by Date Final Inspection by S Date Additional Comments: Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 CK f FEE INFO AMOUNT DUE AMOUNT R��y EppMIITTED CASH RECEIVED BY DATE a ERMIT"NO.t + EH f3.241aRV.I/A51 / % EH i!•2a C (tel(/ \ % i 111