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APPLICATION FOR PERMIT _ p� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES A)d ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 YEAR (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 made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of San Joaquin County Public Health Services. Job Address 5 [�� City Lot Size/Acreage Owner's Name ._ .J • &L&2!CAddress —M r J _ Phone Contractors Address a L icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FD DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl Monitoring well n 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing U Domestic)Private ❑ Gravel Pack D Tracy Type of Casing Specifications M Public EI Other _/0 Delta f Depth of Grout Seal Type of Grout Cl IrriOatton _,Approx.Depth C1 Eastern � Surface Seal Installed by i Repair Work Done U Type of Pump a H.P. I State Work Done _ Wall Destruction 0 Well Diameter Sealing Material i Depth Depth Filler'-Moterial i Depth-~ TYPE OF SEPTIC WORK: NEWINSTALLATION Ll REPAIR/ADDITION M DESTRUCTION eptic system permitted if public sewer is avatlablerwithin 200 feet.) Installation will serve: Re ' encs ommercial Other I Number of living units. Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK: ❑ Type/Mfg Capacity________L No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line A HI ` LE C NG LINE Cl No. & Length of lines _ To[al length%slxe - FILTER BED n Dista ce to nearest: Well Foundations: Property Liner SEEPAGE PITS 11 Depth Size Number SUMPS / L1 Distance to nearest: Wel 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 " J 1 Home owner or licensed agent's signature certifies the fotlowing: "I certify that in the perdormance ofthe work for which this permit is issued, I shall not employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature c ' s 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 f Califprnla." The applican t ca I f r all tt mplete drawing on revyte-ci Signed Title: Date. FOR DEPARTMENT USE ONLY Application Adapted by Date- _Area.. ._ w .. TT 4— Pit or Grout Inspection by Date Final Inspection by - Date Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONHENTAL.HEALTH-DIVI.SI.ON PER![IT/SERVICES _. — 445 N SAN;JOAQUIN, FO BOR 2008, STOCKTON, CA 85201 r FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO PATE PERMIT'N0. " EH 17•NIREV.linsi tJ�7 �f- g3`o C� Lqk? 0go--'253 # EH 1{•2e k