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APPLICATION I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 I P 0 BOX 2009, STOCKTON,' CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby [pada to San Joaquin County for a permit to construct and/or install 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 S vices. Job Address .6-411 -- Cit Lot Size/Acreage Z Owner's Name Address Phone Ih f Contractor Address ehse No. Phone- j TYPE Of WELL/PUMP: SII NEW WELL ❑ WELL REPLACEMENT 1.7 DESTRUCTION Ll Out of Service Well ❑ PLUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 3 INTENDED USE ipTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �J [J Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications I'l Public 1-1 _1` Other 11 Delta Depth of Grout Seal Type of Grout ��l____ I I Irrigation Approx, Depth l I Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth pepth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is i� "available within 200 feet.) f Installation will serve: Residence- Commercial_ Other Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑1 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ I No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest; Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation; Property Line DISPOSAL PONDS o ' .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 i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cartifies 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 mu all or aft re ed inspections. Complete drawing on reverse side. Signed X I Title: ��; �rr � Data: I� R DEPARTMENT USE ONLY { Application Accepted by �I� - -.. _ _ Date Area ko Pit or Grout Inspection by H� Date Final Inspection by Date Additional Comments. Applicant - Returnlll'all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IF O AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. Em 13 24 (,�/(7 + EN 1`.26.IAEV.r/Msi 11 �t�L �v ®� / LJ. j z Ip