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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI } ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 OCT 9 $FF9 (209) 468-3447 1ROWAENTAL HEALTH IF F9 EXPIRES 1 YEAR EROM DATE is 1 �p ,l r. i (Complete in Triplicate) }Yl, I f:st t�` « � t 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 coapliance with San Joaquin County Ordinance No. 549 and 2862 and the Rules and Regulations of San Joaquin County Public Health . Services � � lu Job Address ��I ` City t Size/Acreage fd d Owner's Name ddress Phone —4 • C ntra t Ad ress r License No. /Phone %?/r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM T M DESTRUCTION ❑ Out of Service Well El PUMP INSTALLATION ❑ SYSTEM REPAI�— OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.-LINE FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUM INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dir', of Well Casing omastic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing Specifications Q Aub C1 Other ❑ Delta Depth of Grout Seal Type of Grout Ck Irnuahon Approx, pe th -East n Surface SeatI Inslalled by Repair Work Done U Type of Pump,' �f(� P. - _ State Work Don Well Destruction ❑ Well Diameter sealing Material i Depth \ Depth / Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION L1 REPAIRIAOOITION M DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feat.1 �� s Installation will serve: Residence—41 Commercial — Other x { Number of living units: Number of bedrooms V Character of soil to a depth of 3 feet: .f Water table depth �\ SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments ,\ PKG, TREATMENT PLT.❑ Method of,Disposal �l Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED 171 Distance to nearest; Well Foundation Property Line fR J SEEPAGE PITS 11 Depth I Size Number SUMPS LI Distance to nearest: Well _Foundation t Property Line _DISPOSAL PONDS ❑ — - _� .�. . . — =—�_ _ _ —= ... I hereby comity that I have prepared this application and that the workiwill 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: -l-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, l shall-employ persons subject to workman's compensa- tion laws of California." The applican t csl for II required *196pections. Complete drawing on r v rse side. I Signed Title: 4 Date: FOR DEPA T-MENT USE ONL01/� iY /� ` if Application Accepted by Date -- res--- / - - Pit or Grout Inspection by Date %.Final Inspection b Date Additional Comments: - Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 'i 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMtTTED Gx RECEIVED BY DATE PERMIT•NO. INFO CASH • EH 13-20 iREV,t I h 51 C EH^,42a X /q 0 l