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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 HERMIT ESP,IRE5-- ;,...YEAR OROM DATE-ISSUED (Complete in Triplicate) Application is hereby made,to Sen Joaquin County for a permit to construct and/or install the work herein described. This application is made in coegrliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address V � L E im d d_0414- 1. ___— __ City P-1 PO Lot Size/Acreage I 111 X Owner's Name � 4 C(2de Address 11.2 0^�_[��=j 0 nC.1r1 IQ e_ Phone Contracto( Address License No. Phone TYPE OF WELL/PUMP: _ NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION WOut of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well G7 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 M Industrial 0 Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications \ M Public fa Other 0 Delta Depth of Grout Seal 17Type of Grout Cd Irrigation _,Approx, Depth 0 Eastern Surface Seal installed by Repair Work Done U Type of Pump H,P. State Work Done 'V Well Destruction 1) Well Diameter Sealing Material i Depth Q Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION O DESTRUCTION 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 " SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED Q Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire 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 reguiauons 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 canities 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 compenss• tion laws of California." The applicant ust call for all ra7ked inspections. Complete drawing on reverse side. p n SignedTitls: _ l�(/ .0 l� Date: 191- W- Q F DEPARTMENT USE ONLY Application Accepted by _ ,SeS�s.- ,Q „fn.�� Data Area Pit or Grout Inspection by Date Final Inspection b Date / p 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 2008, STOCKTON, CA 95201 FEE INFO AMOUNT /DuEE�� AMOUNT RE MITTED CASH J RECEIVED BY DATE [ PERMIT"NO. + EH'I. IREV.iiKOi EM