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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION d )F = ;. � _ . P O BOX 2009, STOCKTON, CA 952014: 4 (209) 468-3447E/V JAN ,2-PERMIT EMIRES I YEAR— PROM DATE ISSU a 4 (Complete in Triplicate) �ei4 I tr Application is heresy made.to San Joaquin County for a permit to construct and/or install the work herein"de-C%ib d�AITLs14 I application In made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulat?6ns_-a San Joaquin County Public Health Services. Job Address 4W -�'4A�,© _.. City Lot Size/Acreage i Owner's Name Address Phone r ContractAddress « .x 962- _Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION [ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing h Domestic/Private CI Gravel Pack, ❑ Tracy Type of Casing Specifications ❑ Public fa Other 0 Delta Depth of Grout Seal Type of Grout C.l Irrigation ._._.Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done A- Type of Pump H.P. State Work Done _ Wail Destruction ❑ Well Diameter Sealing Material 6 Depth j Depth Filler Material A Depth t� i TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION M .DESTRUCTION G iNo septic system permitted if public sewer is 4 t available within 200 fastJ (� Installation will serve: Residence— +Commercial_ -Other C 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. Cly:= Method of Disposal r Distance to nearest: Well, Foundation Property Line R LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line 4 SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 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 thaat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- r tion taws of California." i The applicant must cella for all required inspections. Complete`dr"awing on reverse side. c ® Signed X Title: Date: 1-17-ZZ FOR DEPARTMENT USE ONLY Application Accepted by Date / Area. Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments. Applicant - Return all copies tos SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009,. STOCKTON. CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK f CASH REC E IVED BY DATE PERMIT NO. . EM 13.26IAEV. EN 14,26 ((M 1 t ti �- • ,