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APPLICATION 'f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES h ENVIRONMENTAL HEALTH DIVISION 1e 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) • Joaquin County for a permit to construct and/or instal tRules herApplication is hereby made to Scut and Regulations described. s Regulationeof San application is made in compliamce vith San Joaquin County Ordinance No. 5 9 Joaquin County )Public Health Services. �• Lot Size/Acreage City Job Address Phone d�1 ^ Address y Owner's Name I � L icense No. _ 13C ..Phone S Address Contractor WELL REPLACEMENT (1 DESTRUCTION 0 Out of Service We11 ❑ NEW WELL ❑ A OTHER ❑ Monitoring Well Ll TYPE OF WELLIPUMP: SYSTEM REPAIR 0 PUMP INSTALLATION ❑ SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK-^�-� OTHER WELLCI,:_ PITS/SUMPS FOUNDATION AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Cl Manteca Bottom Dia. of Well Excavation ❑ Open 0 Industrial Specifications �A❑ Tracy "`- TYPB of Casing- "� [I Domestic/Private ❑ Gravel Pack Type of Grout I 1 Other F1 Delta Depth of Grout Seal ['1 Public Surface Seal Installed by i I Irrillation -Approx. Depth l I Eastern 3. State Work Done of Pump ---- H.P. Repair Work Done ❑ Type Sealing Material & Depth f We11 Destruction ❑ Well Diameter r Filler!�lsteriel i Depth Depth rmitI d if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION .. �REPAIR/ADDlTION I l -DESTRUCTION s t available rw thin 200 feet.) ✓ Commercial Other -- installation will serve: Residence t '+� i Number of living units: --L Number of bedrooms , - Water table depth r Character of sail to a depth of 3 feet: Capacity No. Compartments SEPTIC TANK fel Type/Mfg �' Method of Disposal PKG, TREATMENT PLT. ❑ Foundation Property Line - Distance to nearest: Well -[J - _ � Total length/size LEACHI11 NG LINEd No. & Length of lines _ pounde`tion -- Property Line FILTER BED n Distance to nearest: Well -=- + r Size Number f SEEPAGE PITS M- Depth - r property Line — SUMPS LI Distance to nearest: Well Foundation 'A DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be dans in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or lonea�seuca�g manner as torbecome sub ectlto w'ogrkman'srtcompensation Ila soof California,"Contractor slhir ng orr sub-conthis permit is ltract nglsignlatu�e„ employ a pe emplo a the peso inn: u certify that in the performance of the work for which chis permit is issued, l shall employ persons subject to workman's componsa- follo tion laws of California." The applicant must All,for all rep .ed i pections. Complete drawing on reverse side. Date: - Title: �- Signed DEPARTMENT USE ONLY Date 1 �~� � Area -.C2� Application Accepted by Pit or Grout Inspection by Date -�--- Final inspection by - ata Additional Comments: Applicant - Return all copies to: EnvironoPublicuntY Services mentalHealthPermit/ServicesCAA 95201 445 N San Joaquin, P O Sox 2009, Stkn, C k FEE AMOU T DUE AMOUNT REMITTED RECEIVED BY CK GATE PERMIT NO. - INFO « EM 13.24 Ir1EV.r/K 71 / EH"11-28 _ ..