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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION '!P 0 BOX 2009, STOCKTON, CA 95201 K (209) 468-3447 YEAR ?R-QM DATE IOUED (Complete in Triplicate) Application is hereby made,to Sant Joaquin County for a permit to construct and/or install the work herein described. This application is smtde in oompliance`with San Joaquin County Ordinance No. 549 and 1562 and the' Rules and Regulations of San Joaquin County Public Health Services. / Job Address �` �� City Lot Size/Acreage dl Owner's Name I �e l,Il r"s Addre�z ��' '� Phone • COM1IrBctor Address � License No. D� Phone ! I TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well Cl PUMP INSTALLATION %—" SYSTEM REPAIR Z-' OTHER O Monitoring Well L7 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 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing Re omestic/Private 0 Gravel Pack, 0 Tracy Type of Casing Specifications 0 Public f-1 Other ❑ Delta.. '' Depth of Grout Seal Type of Grout 11 C3 Irfioation __ Approx,I Depth ❑ Eastern-,? urfaes Seal Installed by Repair Work Done (Type of Pump H:P. to State Work Done _ Well Destruction O Well Diameter f.#Sealing Material Ir Depth _ Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEWINSTALLATION CI REPAIR/ADDITION 'CI DESTRUCTION Irl (No 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 &oil to a depth of 3 feet: T Water table depth SEPTIC TANK. ❑ Type/Mfg f Capacity No. Compartments 5 PKG. TREATMENT PLT, ❑ 1 Method of Disposal Distance to nearest: Well foundation Property Line (T) 1 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 LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ � I hereby certify that I 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 or licensed agent's signature:certifies the following: "I certify that in the performance of the work tot 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 all requir ins , lions. Complete drawing on reverse side. I call a Signed es? Title: to Date: F PARTI++IENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by� — Additional Comments, — Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 1445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 i FEE AMOUNT DUE AMOUNT REMtrTEO CK RECEIVED BY DATE PERMII'NO. t INFO CASH . EH 14•34 IpE1r.s/MSI a EH 13— 4 1.4-20