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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 O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES_ l _YEAR_FRQJM DATE ISSUED (Complete in Triplicate) Application is hereby mads to Ban Joaquin County for a permit to construct and/or Install the work herein described. This application is made in coM2iance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Yy7s _ CitaJa�2& e/s v Lot Size/Acreage Owner's Name ,� Address �1 _i Phone Contractor A68 emer=7 � Address License No,%(46= -Phone TYPE OF WELL UM ) NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ Out of Service ifell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR K OTHER ❑ Monitoring Well ❑ 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing k1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications ('1 Public F1 Other 1`7 Delta Depth of Grout Seal Type of Grout I I Irrigation w Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done dd Type of PumpA."_b� H.P.1 State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth7QQdl Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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 toil to a depth of 3 fast: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Comportments PKG. TREATMENT PLT.❑ MethpAr" Distance to nearest: Well Foundation Property LiR �� s�� FiILL LEACHING LINE C1 No. & Length of lines Total length/size E FILTER BED ❑ Distance to nearest: Well Foundation Prop N'9 f)A7QU1Ne NTY SEEPAGE PITS I I Depth Size NumbeVNVIF SION 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 rsgutations 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 fokowing: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for squired inspections. Complete drawing on re erse side, Signed >' Title: // Date: f`tfSE--ONLY Application Accepted by Date `� Are Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P b Box 2609, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI1,No. r EH 5E-11 IItEv. n sa / 0 O EH 1�•'1a r �