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APPLICATION FOR PERMd I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENV I RONN[ENTAL HEALTH DIVISION N 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I XBO FROM DATE ISSUMS r (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is grade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County Public Health Services. � ..-JobAddress 5 / /11:�[ti 04y Ael City bL° Got Size/Acreage Owner's Name �--. .�Conlractlx �� _Address License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L3 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 C7 Industrial O Open Bottom ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing FI Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H,P. State Work Done Well Destruction . ❑ Well Diameter Sealing Material i Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedroom Character of soil to a depth of 3 feet: Water table depth SEPTIC!TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal j Distance to nearest: Well Foundation Property Line LEACHING LINE Ct No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS It 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 will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Son 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 ! certifiti the following:"I canny that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laves of California." The applicant must call for all requ'ed inspections. Complete drawingon M)" side. Signed; �- Title: Date: _�- - L L FOR DEPARTMENT USE ONLY G� a 2-11 Application Accepted by «►-x ,A -- Date ` -�� l Z Area a ' Pit or Grout Impaction by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ..a� Environmental Health Permit/Services 1 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT Tt/REMiTD fCAArSH RECEIVED BY DACE PERMIT'NO. . EM13.24 HIEN.It"5) I l f�� Xj 9Z� I EM IE46 {�