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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 2009s STOCKTON, CA 95201 (209) 468-3447 R FROM DATE ISSUED . (Complete in Triplicate) Application is hereby made to'San Joaquin County for a permit to conetruct and/or inetall the work 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—. City Lot Size/Acreage ; Owner's Name ._-_ -C�� Address Phone f Contractor �1 /4'L _Address License No. 9 Phone �6 i TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C Monitoring Well I] DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE ,,FOUNDATION ' AGRICULTURE WELL ' OTHER WELL PITS/SUMPS INTENDED 6SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing U Domestic/Private D Gravel Pack 0 Tracy Type of Casing ' Specifications f M Public ill Other 0 Delta Depth of Grout Seal Type of Grout i M trripation — Approx. Depth d Eastern Surface Seal Installed by Repair Work Done v Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW"INSTALLATION 0 REPAIR/ADDITION li t STRUCTION Cl iNo septic system permitted if public sewer is � available within 200 feet.) Installation will terve: Residence� Commercial_ Othor �.4 Number of living units: [ Number ofadrooms g. 4 Character of soil to a depth of 3 feet: �L- Water table depth f SEPTIC TANK ❑ Type/Mfg Cn Al - Capacity �(D No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal r- Distance to nearest: W I F 'Line oundation Property --- 15 LEACHING LINE dl., - & Length of lines Total length/size f! FILTER BED n Distance to nearest: W6,11 Foundation Property Lina I SEEPAGE PITS lli, D pth — 2 Sire !�N`u�mber SUMPS L1 Distance to nearest, We Foundation t_L Property Line— >l DISPOSAL PONDS ❑ I hereby certify that f have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, stats 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 I employ an ! y person in such manner as to become subject to workman's compensation laws of Cakifornia." Contractor's hiring or sub-contracting signature certifies tho 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- tior*�11vv of Galifornla." •�- -. - The applicant a .,call for all r !red i cti n C e drawing on r worse side. Signs Title: _ T ! J .� e. Date: e,...�_ OR DEPARTMENT,.USE.ONLY Application Accepted by Date =�� Area k Pit or Grout Inspection by Date Final Inspection by Date. f �D Additional Comments: Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES 445 H SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201CK 0 f INFO AMOUNT DUE CUNT REMITTED CASH RECEIVED BY DATE PERMIT N"0. ^7 . EN1`. INEV.1ixyr �' .07t X6'3$ lf��"�O 90._ /^_ G +>