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t _�I PPLICATION FOR PERMIT SAN JOAQUINCOUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009, STOCSTON, CA 95201 (209) 468-3447 Y R DATE ISSITRn (Complete in Triplicate) Application is hereby taa4` to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ��// Job Address4bl - ^5 �J � � ` " - -—.City Lot Size/Acreage p Owner's Name AddressPhone Jr ` CoNracior {� ddress Lieense No. Phone TYPE OF WELLINMP: N W WELL ❑ WELL REPLACEMENT Cl DESTRUCTIO t of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia, of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i M Public CI Other ❑ Delta Depth of Grout Seal Type of Grout M Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done 0 Typo of Pump H.P. State Work Done _. Well Destruction Well Diameter �/ Sealing Material 4 Depth �9" Depth_ arld Filler Material 4 Depth TYPE OF SEPTIC WORK: NEYVV-INSTALLATION 0 REPAIR/ADDITION Cl DESTRUCTION G INo septic system permitted if public sower is available within 200 feet.] Installation will serve:. Residi:nce_ Commercial— Other Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity---- No. Compartments PKG, TREATMENT PIT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line r 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 C rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the foilowmg: "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- lion laws of California." The applicant ?,tirad i mpleto drawing on reverse idem Signed - imle: Date: FOR DEPARTMENT USE ONLdelY Application Accepted by Date Ares r.f . Pit or Grout Inspection by _ Date Final In:pection by �' ^ Date t L G'V Additional Comments _ Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2006, STOCKTON, CA 85201 INFO FEE4fAMOUNT DUE /AM.00U1N�TyR�EWTTED CASH CK RECEIVED BY DATE PER'7047 MIITT''NO. i•2a