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APDLICATI6W FOR PERMIT SAN JOAQUIN COUNTY PUBLIC V C ENVIRONKENTAL HEALTHD1 SION 445 N SAN JOAQUIN, PHONEA'1 :052.01)468-3420 P O BOX 2009, STOCg �} ERlit T EXPIRES 1 YF R DkI SU (Complete in Trip ' -ate) Application is hereJoaquin App by made to San County for a permit to const et >�d/oThis application is made in campliance with San Joaquin County Ordinance No. 54Y and 16Wan a es 1.53 Reguiltions of San Joaquin County Public Health Services. �- Job Address J c G'�-a i -n %____ City �� Lot Size/Acreage Owner's Name O. V L►rw lea,4;_1 Address �� Phone Contractor Address -? f't License N3 PhoW12;ZAx,n TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR)Z OTHER ❑ Monitoring Well ❑ 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0'-Domestic/private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'1 Public 1-1 Other Fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth � I Eastern Surfac Seal Installed by Repair Work Done W Type of PumpH.P. State Work Done Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material i Depth 10 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION l I (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 sop.to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments- PKG. TREATMENT PLT.Cl Method of Disposal Distance to nearest: Well Foundation Property,Lins r LEACHING LINE ❑ No. 6 Length of lines - Total lengthisize FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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 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, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The opplican t cap for I uired ins tions. Complete drawing rse side. Signed X Title• Date: ,��7/ �•• T FOR DEPARTMENT USE ONLY Application Accepted by Date ` Z' res Pit or Grout inspection by Date Final Inspection by Date l Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Hnvironmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYDATE PERMI�7'yN,O. • EN!]•II t11Ev.1/K51 EH i1.7E