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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 0 BOX 2009, STOCKTON, CA 95201 PFMIT EXPIRES I Y FROM DATE (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. t � City Lot Size/Acreage V Job Address r CRl ✓Owner's Name . Address t3 � � � Phone Contractor D�.C��' ,�f.------Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ .Monitoring Well C] 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 L] industrial C] Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing Cl DomesticlPrivate ❑ Gravel Pack 0 Tracy Type of Casing Specifications it Public Cl Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth biller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION t INa septic system permit public sewer is vailable within 1 Installation will serve: Residence_ Commercial,.,_. Other Number of living units: Number of bedrooms Character of wil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg CXME��\ PKG. TREATMENT PLT. ❑ ftl V I I 1 1: Distance to nearest: Well FoLmdation.ermi mf �VBro�ny Line Pe LEACHING LINE Ll No. 8 Length .nes Cromp `6= ILI FILTER BED ❑ Dista to nearest: Well F&dp�a]9pq. Lafrppenv+ nb1V1S1— SEEPAGE PITS & I Depth Sire y L lIV Number) f7GQll U SUMPS Ll Distance to At"resl: Well Foundation Property Line DI AL PONDS ❑ I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and rules and regulations of the San Joaquin County ` Horne 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 shell 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 applic nt "1 all for all required inspections. Complete drawing on reverse side. �5;g„,d Title: Data: Y R DEPARTMENT USE ONLY �^ Application Accepted by Date Area h J" Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County .Public Health Services Suvironmental Health Permit/Services, 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 :R, OUNT DUE AMOUNT REMITTEE) CASH RE EIVED BY TE PERMIT'NO. Dip— IN r -__E EH 13-24 InEV.t x m l + {H u•1a L 6k== `s$