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` - APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION NOV 5 19M P O BOX 2009, STOCKTON, CA 95201 ENVIR NMEENTA H MJH (209) 468--3447 "PERMIT EXPIRES I YFSAR FROM DATE—ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. s Job Address€ .' t ti-� �� - City of Size/Acreage Owner's Name Address ,, Phone qL Contractor Address 4Q r License P€o. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR V OTHER 0 Monitoring Well E7 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications M Public Cl Other t❑ Delta Oapth of Grout Seal Type of Grout Cl Irrigation Approx, DepthC ❑ Eastern Surface Said Installed by Repair Work Done Type of Pump V H.P. State Work Done Well Destruction ❑ Well Diameter (� Sealing Material i Depth II Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION.0 REPAIRIADDITION C1 DESTRUCTION CI fNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial_ Other � r 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,Cl Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number i d SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ y I hereby certify that I have preparid 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, l shall not employ any person in such manner as to become subject to workman's compensation taws 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 shsli employ persons subject to workman's compensa-tion laws of California." Q The applicant must call r all required i spections. Complete drawing on feverse side. lt2 Signed X __ Title: — Date; FOR DEPARTMENT USE ONLY G Application Accepted by Date . -` Arae 0 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: _ I Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 tNF0 AMOUNT DUE AMOUNT REMITTED CASH LRECE€VED BY DATE PERMIT'NO. EM 17.7 [REV.%in4l 41J— 17V IX•/ / II fH;�•7a (/ i