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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;1 STOCKTON, CA 95201 I� PERMIT ExPIRES 1 YEAR FROM DATE ISSUED (Completein Triplicate) » ' i7�; Application is hereby made to Ban Joaquin County for a pe. tato construct and/or install the vork herein described. This application is made in compliance with Ban Joaquin County'.Ordinance No. 549 and 1862 and the Rules aad Regulations of San Joaquin County Public Health Services. QQJI City Lot Size/Acreage Job Address Owner's Name Address I Phone Contractor Address ! License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WECL REPLACEMENT C7 DESTRUCTION Li out of Service We ll ❑ PUMP INSTALLATION ❑ ][SYSTEM REPAIR L1OTHER ❑ ldonitoring 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 C] Industrie) O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r.1 Domestic/Private ❑ Gravel Pack © Tracy Type of Casing_ Specifications- - Il Public CI Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material It Depth - - Depth Filler Mterii.l i Depth TYPf OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADOITION I I DESTRUCTION I I,INo septic system permitted if public sewer is available within 200 feet.) I Instatetion will serve: Residence— Commercial Other ' Number of living units: Number of bedrooms Character of sa to a depth of 3_feet:. a Water table depth SEPTIC TANK., ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT..❑ Method of Disposal Distance to ne6rest: Well Foundatlon IProperty Line LEACHING Li NE .No:& Length.,of lines IM Total length/size FILTER BED i .0 Distance to nearest: Well Foundation Property Line SEEPAG&ITS', 11 Depth Size LNumber SUMPS Ll Distance-to nearest: Well 0 Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt 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: "1 certify that in the performance of the work for which this permit is issued, I shat)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 folbwing:"I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." `1 The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title,� Date: I , FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspoction by Date I� Final Inspection by Date Additional Comments: !� - I Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 it FEE AMOUNT DUE AMOUNT REMITTED �� ASB RECEIVED 8Y DATE PERMI 'NO. INFO + EH 13-14 IR{V.i/R 51 - EH 14-M `