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APPLICATION SAN JOAQUIN COUNTY PUBLIC, HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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 compliance with San Joaquin County Ordinance No. 549 and lend the Rules and Regulations of San ; Joaquin County Public Health Services. City Lot Size/Acreage Job Address Owner's Name Q(f Address s Phone dress S trp lo.�� Phone Contractor WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well L1TYPE OF WELL/PUMP: NEW WELL ❑ PUMP INST LLATION ❑ SYSTEM REPAIR C7 OT R ❑ Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC T EWER LINES EL DISPOSAL FL�PITS/ LINE FOUNDATION AGRICULTURE WEL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREAL CONSTRUCTION SPECIFICATIONS pia. of Well Casing 5 Industrial C] Open Bottom ❑ Manteca Dia. of Well Excav tion DK_Oomestic/Private *tGravel Pack7 C] Tracy Type of Casin g— E�a Specifications/Type of Grout 'i F] Public [I Other n Delta Depth of Grout Seal I I Irrigation Approx. Depth C044astern Surface Seal Installed by Repair Work Done 0 Type of Pump - H.P. �5jtate oe -7� Sealing Material & Depth ]S,� € Well Destruction OLQ_ Well Diameter V Filler Material i Depth Depth 3� � i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I i .avi septic system permitted it public sewer is avilable within 200 leel.i i 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.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS la 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 iignature 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 ce ify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- tion laws of Caiifornf The applic all r all requ" d ins ctions. Complete drawing on rVarse side Signed X Title: Date: FOR DEPARTMENT USE LY Date rea Application Accepted by I Pit or Grout Inspection by Date 2 Final Inspection by Date l smell 4.2 z 7 Additional Comments: �� Applicant - Return all copies to: San Joaquin County Public Health Services ��`, Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 d� �a�� +fl�f/d eys4o FEE AMOUNT REMITTEO CK RECEkVED BY DATE PERMIT"N0. IN AMOUNT D E ASH k)xqq a / J j � EH 13-24 IREV,I I n sr EH 14.26 r