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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 _PERMIT EXPIRES 1 YEAR FROM_DATE ISSUED (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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. / Job Address I (7 Cv f -e City �t`� Lot Size/Acreage o� p f 6.2 7/ m Owner's Nae Address Phone/ / y ^rf Contractor.6"` 4,,," Pry Addres - S `j r License No. �� Phone Q TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR © OTHER ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.,..�V-PROP. LINE (�rr # FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ____ I r INTENDED.USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIgNS �1 ❑ Industrial ❑/open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casing Domestic/Private iGravel Pack ❑ Tracy Type of Casing_ PLIC. Specifications �6a ('I Public I"1 Other. I1 Delta Depth of Grout Seal - mfg ✓off, f Type of Grout—fin i I I Irrigation lW/AApprox. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth i Depth Filler Material i Depth ~7 TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is _ available within 200 Ieet.I Installation will serve: Residence T Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: Water table depth i SEPTIC TANK a'❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Ll r Method of Disposal t Distance to nearest: Well Foundation Property Line t LEACHING LINE ❑ No. b Length of lines Total length/size i FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i 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 applicantcall to all requ' inspections Complete drawing on rave side. Signed Title: Date: / r FOR DEPARTMENT USE ONLY Application Accepted by Data Area_r, Pito Grant nopection by_ Date,, Final Inspection by, Date�a' & Additional Comments:__( /, �` y Applicant - Return all copies to: San Joaquin County Public Health Services' Environmental Health Permit/Services .445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AAM(O/UUNT DUE AMOUNT REMITTED CASH RECEIVED BY ,t DATE PERMIIT'NO. . EH13.24(REV.tiR6r EM 14.98