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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95203. (209) 468-3447 (Complete in Triplicate) Application is hereby ma.de,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules a.nd Regulations of San Joaquin County Public He��a��l,,,th Services. f Job Address ` `// k City.97& 0 Lot Size/Acreage Owner's Name yl�'A t r� c� f1-f Y{- . _ Address Phone Contracts t'-wel Address S��S �� .529? License No f 6 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT !1 DESTRUCTION Cl Out of Service well ❑ PUMP INSTALLATION ❑ ti SYSTEM REPAIR OTHER ❑ Monitoring well C7 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 Cl Industrisl ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications [7 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout Ci IrriUation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction O Well Diameter +l Sealing Material & Depth Depth 1 ]�_°�_ Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIR/ADDITION M DESTRUCTION CI (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 soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg 3 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED d Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 call for ail quire insPections. Complete drawing on reverse side. / �} Signed Title: r�� Date: _--12 OR ARTMENT USE ONLY ZIR Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection Additional Comments: Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES } "'ENVIRONfdRN1AL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED 8Y DATE PEArMI7 N0. . EH 13,24 IREV.I/n 5) ` 0 ENq�.ja CJ CJ f C L J