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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009111 STOCKTOK,. CA '95201. Y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,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 Publ Health Services. PN PIJob Address City Lot Size/Acreage , Address `f ",V�'L� - Phone ✓Owner's Name � � Contractor Address jez License No. � T Phone �— TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 i +( � 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N,.. C:1 Domestic/Private Cl Gravel Pack L1Tracy Type of Casing_ Specifications VI Public .-e Cl Other r Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I i Eastern Sur-face Seal Installed by Repair Work Done U Type of Pump H.P. / "� State Work Done Well Destruction ❑ Well Diameter, Sealing Materia1,& Depth Depth , •Filler Material i Depth 'L AI TYPE OF SEPTIC WORK, NEW INSTALLATION I I REPRIADOITION I k DESTRUCTION INo septic system permitted if public sews available within top feat.) Installation will serve: Residence_ Commercial Number of living units: Number of bedrooms y Character of soil to a depth of 3 feet: ; Watertable depth } SEPTIC TANK ❑ Type/Mfg Capacit No. Compartments f PKG. TREATMENT PLT. ❑, Method of Disposal. Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of s Total length/size FILTER BED [7 Distan nearest; Well I Foundation Property Lina } SEEPAGE PITS I I Depth Size Number t SUMPS L-1,., Distance to nearest: Well Foundation Property Line , APONDS ❑ 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 sy ;."� Home owner or licensed agent's Signature certifies the following: "I certify that in the performance of the work focwhich this permit is issued, I shall not employ any person.in such manner as-.to become subject to workman's compensation laws of California." Con'tractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for'whichsthis permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicanil ust tail for all required inspections. C mplate drawing an reverse side. �( Signed f '' Title: Date: 7713 - ✓ DEPARTMENT USE ONLY k Application Accepted by 49CA A 31 h POP 14 A Date to Pit or Grout Inspection by ate .Fin I lnapection by Date S �� Additional Comments: fr 5 j3 ss Applicant Return all copies to: San Joaquin County Public Health Services J'A. Environmental Health Permit/Services ►�Rii�{Y 445 N San Joaquin, P O Box 2009,iStkn, CA 95201 G FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO, INFO . EM13.24 11tEV.1/9 91 —2l: EN '1428 !!