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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 PERMIT ESPIRES 1 YEAR FRQM DATE ISSUED (Complete in Triplicate) Application In 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. �� ,�,��,/ Job Address �/ �74��//I��Y�Gt.. 1t� City Lot Size/Acreage Owner's Name y /�-� �e_ Address Phone M/_ � Contraclor A� en'se No. Ph on TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT C_l DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 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 ❑ industrial O Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing ertteatic/Prlvate 0 Gravel Pack 0 Tracy Type of Casing Specifications M Public 1-1 Other p Delta Depth of Grout Seat Type of Grout 0 Irrigalion Approx. Depth 0/Ea�stern /Surface Saul Installed by Repair Work Done ❑ Type of Pum 7.J H.P. I State Work Done Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material h i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION L7 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 Capacity. No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. 6 length of lines Twat length/size FILTER BED I Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LA Distance to nearest: W" 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, stale laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I canify 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 hir n.g or,sub-contracting signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons 36ject;lo workman's compensa- tion laws of California." The applicant sit caII fo aft r aired inspectigns. Complete drawing on rev se side. �. SIZ ig d �^ eP Title Date: s F DE RTMENT USE ONLY r� Application Accepted by Date ` tAiea�y'i 121 fy i�ty Pit or Grout Inspection by DateFinal lncpeclion by Data G Additional Comments: r '1 Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 FEE K INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO- a EH 15-24 IREV.1/N51 LS['H J Aql � P 7426 �,J i