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I APPLICATION FOR PERMIT in SAN JOAQUIN COUNTY .PUBLIC HEALTH S9RVI 7 ENVIRONMENTAL HEALTH DIVISION RECEIV`17`7 P O BOX 2009, STOCKTON, CA 95201 J U N 13 1991 (209) 468-'3447 ENVIRONMENTAL HEAD i"f PERMYT_,EXPIRES 1 YEAR PROM DAZE ISSUSDr n R r• (Complete in Triplicate) EnrvllT/t>mq lGLO Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coupliance with.San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of Ban Joaquin County Public Health Services. Job Address `1_ __ x� 3 T City • Lot Size/Acreage S Owner's Name ✓ Address Phone ContractoGke Address License N Phone TYPE OF WELL/PUMP.. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION F-___ SYSTEM REPAIR UW-' OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ind tial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing tic/private ❑ Gravet Pack ❑ Tracy Type of Casing Specifications Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout A� CJ Irrigation -- ',Approx. Depth 0 Eastern I Surface Seal Installed by " l Repair Work Done 0 Type of Pump ./ ! _ H.P. ___ _ State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/AODITION L7 DESTRUCTION G INo septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS Ii Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C1 i 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 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 shall employ persons subject to workman's compensa- tion laws of California." The applicant must c for all required inspgctions. Complete drawing on averse side. f Signed Title: Date: FORD PARTMENT USE ONLY Application Accepted by Date Area Pit or Grout lnapec;ion by Date Final Inspection by ate 9 Additional Comments: y Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 FEE /INNFO°� AMOVNT DUE AMOUNT REMITTED - CASH RECEIVED BY D/A��..TE PERMIT'NO. • EN 13-24 IRfY.1/ siYJ