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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ., ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 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 conpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San - Joaquin County Public Health Services. Job Address City LOP Lot Size/Acreage a2 Owner's Name "' ' L� r✓W&Z VAdress ! r Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ lllPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER X 6p,iM' ng Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom 0 Manteca pia. of Well Excavation Dia. of Well Casing EI Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing- Specifications l'I Public C] Other I-1 Delta Depth of Grout Seal Type of Grout I i Irrigation _-App?IIsi. Depth l I Eastern Surface Seal Installed by r Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth a}� Depth Filler Material i Depth } TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I ) DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_,.—. Commercial_ Other Number of living units: Number of bedrooms b . D Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments m PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BEDf° n Distance to nearest. Well Foundation Property Line pp X.J SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 sub-contracting signature certifies 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 ust call for all Ire tions. Complete drawing on reverse side }� /� I Signed Title: Date: ell i FOR DEPARTMENT USE ONLY 4� _;r o*02/� Application Accepted by Date Area ; Pit or Grout Inspection by Date Final Inspection by T Date L"',-Zf!;�� Additional Comments.M— !Z?— "a Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITVNO. . EH 13-24 IREV.I/n5i EH 1 • �� i 426 `