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�I APPLICATION !I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ii 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for permit to construct and/or install the Work herein described. This application is made in ceipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public HeaIZvices. Job Address r i City Lot Size/Acreage Owner's Name ^y - -" � Phone t� Contractor Y Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 17 OTHER ❑ Monitoring Well 0 DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER-WELL PITS/SUMPS .I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS * Industrial 1 ❑ Open Bottom ❑ Manteca Dia. of Wali Excavation Dia. of Well Casing * Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications 9 I'I Public Cl Other Fl Delta Depth of Grout Seal Type of Grout I I Irrigation n:Approx. Depth I i Eastern Surface Seal Installed by �y Repair Work Done ❑ Type of Pump H.P. State Work Done _t Well Destruction ❑ Well Diameter Sealing Material h Depth Depth , Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted it 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 o'f 3 feet: Water table depth ' 'SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ��. Method of Disposal Distance to nearest: Well Foundation Property Line 0 LEACHING LINE C1 'No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line -w I! SEEPAGE PITS I 1 Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ! I hereby certify that t 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 no't-r, 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 certify that in the performance of the work for which this permit i3ls6ued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant c f all rl� 's p aqui inspections. Complete drawing on reverse side. Signed II - Title: - - Date: J_� P DEPARTMENT USE ONLY ! �� Application Accepted by dam, �� , 11Date Area i� Pit or Grout Inspection by Date Final Inspection by XM Data i Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services f� Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE' AMOUNT REMITTED CASH RE VED BY p TE PERMIT'NO. EFS 13-24 iREV.tInst 19l/!' � ��y9 EH 7616 Y �!