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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCKTON, CA 95201 (209) 468-3447 R (Complete in Triplicate) Application is hereby made to $"-Joaquin County for a permit to eonatruct and/or install the work herein described. This application is made in compliance'vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City t Size/Acreage Owner's Name �� Address Phone 1 ContraS�� dre � G" 3� License No. U0--phone TYPE OT WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out or Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR 01� OTHER ❑ Monitoring Well C7 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 + f7Indu I El Open Bottom ❑ Manteca Dia. of Well Excavation a _'Dia. of Well Casing omas Iprivate Cl Gravel Pack ❑ Tracy Type of Casing Specifications M Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout MI Irrigation _ Approx. Depth ❑ Eastern' Surface Seal Installed by Repair Work Dons Type of Pump*. H.P. __ _ State Work Done Lai a Well Destruction ❑ Well Diameter Sealing Material ✓V Depth Depth f Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION Cl 1No septic system permitted if public sewer is vl i available within 200 feet.I Installation will serve:y Residence Commercial Other w f Number of living units: _.z- Numbir of bedrooms .t Character of soil to a depth of 3 feel:"' Water table depth SEPTIC TANK. ❑ T /Mf "e Y� g Capacity Na. Compartments PKG. TREATMENT PLT, 0a_ Method of D'_ I * ' ""Distance to nearest: Well Foundation. ``" `Property Line a �p� [ E LEACHING LINE Cl No. 6 Length of lines { '' �� Total length/size FILTER BED Ci Distance to nearest: Well Foundation Property Line i OOO�LTY AN 301 U : cF� SEEPAGE PITS 11 Depth Sirs Number �UBC F 7�� T ALiH 1]1VtJ''�i' SUMPS LI Distance to=nearest: Weil Foundation Property L6NIRV1�4�� i.rn�' 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 cenifies 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 subcontracting signature certifies the following: "I Candy that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's componsa• I tlon laws of California," 1 The applicant must call for 1 equired inspepi ns. Complete drawing on arse side. ' Signed Title: Dotal �� I i FOR DEPA TMENT USE ONLY Application Accepted by Data 2- Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments; t Applicant - Return all copies to: ISAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES W �ENVIRONIlENTAL.HBALTH DIVIAIeN PERMIT/SERVICES w1v 1445 N SAN JOAQUIN, P O OS, STOCKTON, CA 95201FEE INFO AMOUNT DUE A OU[N^T REMITTED `CK RECEIVED 8Y DAT/E/ PEAMIT'NO. . EN 13-24 IRf4. 61 PIP VS&Vt 7 u 4 3o-7/ EN 1{.Ze rr /