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APPLICATION FOR PERMIT r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j ENVIRON![ENTAL HEALTH DIVISION PAV9t41 445 N SAN JOAQUIN, PHONE (209)468-3420 RECEIVED P O BOX 2009, STOCKTON, CA 95201 A r)lJ 2 3 mi 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN60AQ1JIN C01 (Complete in Triplicate) p08t 11EALi'HSf i ENVIRt`N'MP ErNTAL NcALI,n Application is hereby made to San 'Joaquin County for a permit to construct and/or install the work herein described. This spplication is made in cea►pliance 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 E Owner's Name Address Phone Contractor / Address flue No.Vk,'i.-2-6 Phone TYPE OF WELL UMP. NEW WELL ❑ +. WELL REPLACEMENT FI DESTRUCTION ❑ Out of service well ❑ PUMP INSTALLATION ❑ ,,SYSTEM REPAIR l OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK, .i. SEWER LINES DISPOSAL FLO. PROP. LINE -_,,,_ - FOUNDATION ' ( AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom O Manteca 7== Die. of Well Excavation Ois. of Well Casing 1 ,fir kt Domestic/Private ❑ Gravel Pack f ❑ Tracy Type of Casing_ Specilications I'1 Public C] Other ❑ Delta ;t Depth of,Grout Seal Type of Grout I i Irrigation _.Approx. Easter Depth I I n L a I Surface Sel4l talled by Repair Work Done T' Type of Pump 's„ H.P. _ State Work Done Well Destruction D WeII Diameter ; Sealing Material A Depth " Depth t Filler Material Z Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is I available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soli 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 ❑ No. & Length of lines Total length/size j FILTER BED ❑ Distance to nearest: Well Foundation Property Line � SEEPAGE PITS 11 Depth Size Number t SUMPS Ll Distance to nearest:_.._. Well Foundation Property Line i 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 1 Home owner or licensed agent's signature certifies the following: "1 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." Contrectoi s hiring or sub-contracting signal 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 compen tion laws of California." The applicant mucall for all required inspections. Complete drawing on reverse side. Signed X Title: ll� Date: R DEPA NLY Application Accepted bnets t3a . Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: Ban Joaquin County Public Health Services Environotental Health Permit/Services i .445 N San-Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE INFO PERMiT'NO. • EH1 324 IIIEV.I/A5I EN 14.28 ' . E7 P �j�'.� r Cc) wxr