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-A 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 in hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 4 Job Address Gf"�"2 f�. �R- CityG Lot Size/Acreage ffowner's Name Address ' [ Phone Contractor �" J [ Address- C1I �� 1i1� i L se Ivo,i ea 5� 3 Phone b oy!3 TYPE OF WELL/PUMP: NEW WELL IDWELL REPLACEMENT ❑ DESTRUCTION X Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER 0 Monitoring Well ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'1 Public CZ Other F-I Delta Depth of Groan Seal Type of Grout I i Irrigation —Approx. Depth i I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _ State Work Done T Well Destruction ❑ Well Diameter Sealing Material & Depth Depth . Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I i INo septic system permitted it public sewer is 11.1 available within 200 feet. Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. C) Method of Disposal Distance to nearest: Well Foundation Property Line y LEACHING LINE Cl No. B Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property.Line SEEPAGE PITS T v. 11 Depth ' Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 employ any person in such or asto become subject to workman's compensation laws of California:','.Contractor's hiring or sub-contracting signature certifies the following: "I y 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 Califor r. The,.applicant s ii required inspections. Complete drawing on reverse side.. _ �gnecl Title: Date: Z!_s_-�� FfkR DEPARTMENT USE ONLY ��j ii Application Accepted by4r� Date 1 g ` 3 Area C;,2— Pit rout spection by Date `� Final Inspection by Data • Additional Comments: _, 0 / f Applicant - Return"al copies to: San Joaquin County Public Health Services ` Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CEIVED BY TTE PERMIT'NO. . EH 1444e•21(REV.i/Mal EH 1.. . f717 Ll� O V� X W O X (✓' �/ �