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A APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 2009, STOCKTON, CA 95201 -,- (209) 5201(209) 468-3447 YEAR O CT 2 11 "3 (Complete in Triplicate) ENVIROMMENTAL HEALTH Application is hereby made,to San Joaquin County for a permit to construct and/or install�herivark/k�ereitilKekerlbed. This application is made in compliance vith Ban Joaquin County Ordinance No. 549 and 1862 and !h'� �tuWee ancr egulations of Ban Joaquin County Public Health Servic a..,/ 1 Job Address LZ_l U`t City �� 'V Lot Size/Acreage Owner's Name Address Phone r ofirgG q r 4 l 'LicenSe o Phone TYPE OF WELL/PUMP: NEW WEL ❑ WELL REPLACE ENT Cl DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIF� OTHER C3Monitoring well L7 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 L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �omestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications 4- ❑ Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout M Irfigation Approx. De th Eastern Surface Seal Instalied ` Repair Work Done Type of Pump H.P. y tate ork Do e Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is available within 200 feat.) Installation wHl serve: Residence �� Commercial_ Other Number of living units: Number of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity--- No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearast=--- _Well -Foundation Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED 1_1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire I Number SUMPS LI 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 regulations of the San Joaquin County Some 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 following: "I certify that in the performance of the work for which this permit is issued, I shah empioy persons subject to workman's compensa- tion laws of California." The applicant mus fOr all ro spgct'on"C,o(mpiele drawing on raver side. l/ioSigned ?�_ ___ _..__.��!U� Title: Date: /a FOR DEPARTMENT USE ONLY 3 Application Accepted u Date A D Area Pit or Grout Inspection by Date Final Inspection byt Nk `_�� Date Additional Comments: 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 95201 43 INFOuAMOUNT DUE AMOUNT f�EMITTED GASH RECEIVED 9Y DATE PERMI NO. + EM t3•24 Ir1EV.I I+•5s EH 1426 5f a d� Ss