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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 I MIT UEJggSS 1 YEAR rROId DATE ItSSUBD (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 1862 and the Rules and Regulations of San Joaquin County Public Health �Services. Job Address ./ •" � u _ City t Size/Acreage i .— Owner's Namew" / AddressPhone Contractor Address XZ icense No. Phone/ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of notserving Well a PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 f7 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications TV"Public CI Other ❑ Delta Depth of Grout Seal Type of Grout. n Irrigation .Approx. Depth ❑ Eastern Surface Seal installed by Repair Work Done LJ Type of Pump H.P. State Work Done_ Weil Destruction ❑ Well,Diameter Sealing Material i Depth Depth ' Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDIT15 DESTRUCTION G Mo septic system permitted if public sewer is I - available within 200 feet.f l Installation will erve:-.-Res'idence..x--.Comrnerciil.— Other Number of living units: Number of bedrooms r Character,of soil to a depth of 3 feet- r Water table depth SEPTIC TANK -❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT: ❑ 4 �•' � Method of Disposal z :. w_y t 0islailce to nearest:— Well Foundation Property Line LEACHING LINE Iii` -No. & Length of lines D Total length/size FILTER BED ❑ 'Distance to nearest: Well T S:41---- Foundation �� Property Line�® SEEPAGE PITS Depth �� -- .Sire Number SUMPS LI Distance to nearest: Well Foundation tea' Property Line DISPOSAL PONDS ❑ .i r I hereby certify that I have prepared this application and that the work will tie 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, 1 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 conifies 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- tion laws of California." The applicant must or all ray a inspections. Complete drawing on reverse side'.y Signed (V/ Title: Date: t FOR DEPARTMENT USE ONLY Application Accepted by X Data �"Y Area 1 i or Grout Inspection by Date :� `Final Inspection by . Datel4yEU Additional Comments _ i _ -- Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION. PERMIT/SERVICES 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 IFEE I AMOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATEElo PERMIT NO. INFO • EH 12.24IREV.I/✓f SI L J2--3- ` CH A-A