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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 PERMIT R rROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is »rade in eoVlianee vith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. -,tr, Job Address City_ Lot Size/Acreage -. Owner's Name . •• - - �_ Addr"ass _ T- 1 Contractor °' Address License No. hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well RUMP-INSTALLATION ❑ SYSTEM. REPAIR ❑ OTHER O Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION `^ AGRICULTURE WELL OTHER,WELL F , PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;- F1 Industrisi ❑ Open Bottom ❑ Manteca Dia`of Well Excavation Dia. of We)] Casing U Domestic/Private ❑ Gravel Pack -❑,Tracy ;,, Type of Casing Spicificationi M Public ill Other ❑.Delta '+ Depth of Grout Seal Type of Grout CJ lchoation Approx. Depih 0 Eastern Sfrfaee Seal Installed by Repair Work Done U Type of Pump H.P. State Work Donor z Well Destruction ❑ Well Diameter Sealingrka�erial & Depth Depth Filler Material & Depth LP TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is _ available within 200 feet.] Installation will serve: Residence _ Commercial father -' Number of living units: --,I— Number of bedroomss `� F ,. . Character of eoif to ■ depth of 3 feet: ..._,.. �'g�Q'� 2!1- -- _Water,table depth SEPTIC TANK 0 Type/Mfg Pa. Capacity - No: Compahm&461� PKG. TREATMENT PLT. ❑ 1w we,(-4 �.�-- Method of Disposal Distance to nearest' Well Foundation � Property Line LEACHING LINE No.,& Length of lines -; Total length/si:e FILTER BED 1.1 Distance to nearest: Well _. Fauntlation Property Line r SEEPAGE PITS I I Depth LZ2T= Size Number_ SUMPS Distance to nearest: Well Foundation 19-b P Property Lina i 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 for which this permit is issued,JI shall not employ any person in such manner as to-become subject to workman's compensation laws-o9_Cefifornia.';Contfactor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this;permit is issued-11 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for reWd inspec ions. Complete drawing on reverse side. 00 r15 Signed X �«./ _-___- Title: Date: ,FOR DEPARTMENT USE ONLY Application Accepted by Date ? Area .�ier r lu�r / Zu Pit or Grout inspection by Date Final Inspection by Dats Additional Comments: _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC.HEALTH SERVICES ENVIRONMENTAL REALTH AIVISION PPR1lIT/SERVICES T 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'N0, INFO CASH- • EH 17-241REV,siw51