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APPLICATION FOR PERMIT --'�` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ; P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT ESPIRBS 1 YEARPR9A DATE ISE11M t (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 and Regulations of San Joaquin County Public Health Services. _ Job Address City Lot Size/Acreage Owner's Name v Address \ J - Phone Q�j • tor re nse 4ff,?/(,Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well C_l PUMP INSTALLATION SYSTEM REPAI - ❑ OTHER ❑ Monitoring Well Ll DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE j FOUNDATION ,AGRICULTURE WELL,L_=__ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM•AREA C_ON5,TRUCTION SPECIFICATIONS- r.1 Industrial ❑ Open Bottom ❑ Manteca Dia/of Well Excivaiion "" Oia. of Well Casing j �pmestic/Private 0 Gravel Pack C3 Tracy Type of Casing f .y Specifications M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout Ml Irrigation Approx. De oih EsternFepair Work Done {] Type of Pum ! H.P: ..--, State Wark Dona Wall Destruction O Well Diameter er � Sealing Material i.Depth r Depth 1Filler Material Ii Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADOITION.M DESTRUCTION Cl (No septic system permitted if public sewer is _N w»+ ., available within 200 feet.) l Installation will serve: Residence -Commercial= Other, - Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK..." ❑ Type/Mfg N' Capacity No. Compartments PKG. TREATMENT PLT. 0 — r Method of Disposal . Distance to nearest: Well, i Foundation Property Line LEACHING LINE ❑ No. A Length of lines ) Notal length/size FILTER BED n Distance to nearest: Well Found`atio'n'— Property Line i SEEPAGE PITS L 1 Depth Size L l i t -- Number SUMPS LI r Distance to nearest: Well Foundation Property Line T_.-..i�DISPOSAL_PONOS__0 _f s 4 I hereby comity that I have prepared this application and that th`e.wark 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 comity that in the performance of the work for which this permit is issued, t 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 applican a call rforC, required inspections, Complete drawing on revpVse side. Signs Title: Date: FOR DEPARTMENT USE ONLY .gg Application Accepted by Wow---- Date 9-' /D Ares Pit or Grout Inspection by Date Final inspection by % w Date to D Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICE8 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 FEE INFO AMOUNT DIVE AMOUNT nEMlTTED CASH RECEIVED BY DATE PERMIT"N0. . EN 1124 1REV.t I M 51LA 1 EN 74.16