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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-- YEAR PROM PAI&JAaM y (Complete in Triplicate) N 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 coa>pliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Healt ery ee ` Job Address ' City Lot Size/Acreage :5�40 _ r! Owner's Name Sk AddressS VQ_IC —_ Phone��g "� K Contractor uf► ?ddress r �dDCS mo License No. zab Phone G2B3�1''l8 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well �y►�'$otrZlNl�S DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE T�p� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �, y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation V /Ngib -,i __ Dia. of Well Casing v X Domestic/Private C7 Gravel Pack Tracy Type Of Casing Specifications M Public (! Other t1a►A146 13 Delta Depth of Grout Seal 1Of•�c5-�46 Type of Grout"&X `•� CJ Irnuation _ LrApprox. Depth ❑ Eastern Surface Seal Installed by 1-A Repair Work Done v Type of Pump,�'' '''� H.P. Stats Work Done Well Destruction O Well Diameter` Sealing Material & Depth 10 f Filler Materiae Depth ,� l 4 Depth � P TYPE OF SEPTIC WORK: NEW INSTALLATION.0 REPAIR/ADDITION M DESTRUCTION CI {No septic system permitted if public sewer 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 feel: r Water table depth SEPTIC TANK 0 Type/Mfg Capacity - No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED f=) Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 s 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 Josquin'County Home owner or licensed agent's signature cenifies 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 cenify 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." The apOicanAm4st c I for ed inspections. Complete drawing on reverse side. �p�, Signed Title: � �C►.+` u'S D t�'i �''""" Date: " C' FOR DEPARTMENT USE ONLY Application Accepted by Dat Area Aj Pit or Grout Inspection by Date Final Inspection by Date VV VV Additional Comments: — Applicant - Return all copies to:x SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION.PERl1IT/SERVICES 445 H SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. )NFO �� CASH ♦ EH13•24[REV.1?It61 89.E EH A-26