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APPLICATION FOR PERMIT �i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 (209) 468-3447 R (Complete in Triplicate) Application is hereby made3to San Joaquin County for a permit to construct and/or install the work herein described. This application is tttade in coawliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules sad Regulations of San Joaquin County Public Health Services. Job Address , [� tit City Lot Size/Acreage Owner's Name � � ��. Address t' a C.-I �t Phone az' Coniractof sa Q•T _Address License No. Phone TYPE OF WELL/PUMP: n NEW WELL 0 WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ _ _ SYSTEM REPAIR ❑ 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 c] Open Bottom El Manteca Dia, of Well Excavation Dia, of Well Casing CJ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications A Public (".1 Other CO Delta Depth of Grout Seal Type of Grout CJ Irrioalion �.'Approx. Depth 0 Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction O Wait Diameter Sealing Material i Depth Depth Filler Material i Depth � TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M OESTRUCTION iNo septic system permitted if public sewer is t t l available within 200 feet.) Installation will serve: Residence— Commercial.•.,,^ Other Number of living units: Number of bedrooms Character of soil to a depth o1 3 feet: Water table depth t SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,0 i Method of Disposal Distance to nearest: Well Foundation Property Line t ,F LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BEA Cl Distance to nearest: Welt Foundation Property Line SEEPAGE PITS II Depth Size Number SUMPS 'LI f Distance to nearest: Well Foundation Property Line .r ' DISPOSAL PONDS ❑ I hereby certify that i have prepared this application and thal the work will be done in accordance with San Joaquin county ordinances, state laws, and IE rules and regulations of the San'Joaquin County F Horne owner or licensed agent's signature canities 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 taws of California," Contractor's hiring of 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 applicant mu all for 4frequirred inspections. Complete drawing on reverse side. I Signed t Title: _ 167 r�-»=p _ _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area _[- Pit or Grout Inspection by Date Final Incp tion by Date 0 "� S�3 Additional Comments: — I 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 98201 FEE AMOUNT DUE AMOUNT REMiTTEO CK RECEIVED BY DATE PERMiT'NO. INFO �CASH f) EH 13-24[REV.mq s) EH