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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 aMIT EXPIRES Y YEAR PM PATE IS9= i (Complete in Triplicate) Application Ss hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ! Job Address /•� , �Cijty� Lot Size/Acreage le-IhE Owner's Name Address r `�` Phone Q yQ I Contractor �ddress , License No uPhone TYPE Of WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT M OESTRUCTIO t of Service Well O . PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J * Industrial 0 Open Bonom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing r * DOrttesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications J ❑ Public Ill Other O Delta Depth of Grout Seal Type of Grout M Irrigation _Approx. Depth D Eastern Surface Seal Installed by Repair Work Dons 0 Type of Pump r— H.P. State Work pone . a Wall Destruction A0 Wall Diameter Sealing Material a Depth 6, A . Depth r Filler Material Depth y rtwl TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION D INo septic system permitted it public sower is available within 200 feet,I Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms (� Chirracter of soil to a depth of 3 feet: Water table depth Vl SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line -Dri LEACHING LINE ❑ No. 8 Length of lines Total iength/size FILTER BED [D Distance to nearest: Well Foundation PropenV Line SEEPAGE PITS i i Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ U I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,stats laws, and G rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: 'V 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 Califomia."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the pettormance of the work for which this permit is issued, I shall employ persons subject to workman's comport" tion laws of California." The applicant st trod i mplete drawing on rev Be Ass- Signed X / .r�I..-e-� -'FiAo: �_ pate: FOR DEPARTMENT USE ONLY Application Accepted by 44 Date g^ —'a Area 421 Pit or Grout I tion by __ Date Final Ins G tnpec Faction by Dau j V 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 2000, STOCKTON, CA 96201 FEECINFO AM/OUNT Df1UE AMOUNT REMITTED CAS,RECEIVED BY DATE PERMIT NO. tN 1�•7�Otty.11 61 V�'-0 .0ov /��• EN-.1.76 V