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r.. 1 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 `" P" e�w ✓ PERMIT EXPIRES x YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to San Joaquin County for s permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance"No. 5159 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job AddressZ ' Cd 4 City' Lot Size/Acreage a Owner's Nam $46/2 / t l�,Gt� ,4Udress ��^� Phone Contractor '— Address d /f License No dqd Phone +� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial , ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 7 Dia. of Well Casing >fDomestic/Private l ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications t Il Public fTOther f-1 Delta Depth of Grout Seal Type of Grout l I Irrigation _,.Apprals. Depth I J Eastern SX Seal Installed by t Repair Work Done Type of Pump . H.P. State Work Done Well Destruction © Well Diameter r Sealing Mate%i ' & Depth Depth Filler Naterialfi'"Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDiTION'I ! DESTRUCTION l I {No septic system permitted if public sewer is available within 200 lest.I AZ 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/MfgCapacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl . No. & Length of tines Total length/sire FILTER BED FI Distance to nearest. Well Foundation Property Line I SEEPAGE PITS I I 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 r Home owner or licensed',agent'es.Signature•cenifies the_following:�'l ertify ihat',in the performance of the work for which this permit is issued, I shall not employ any person in such mariner as to became 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 must r 11 required inspect i S. Complete drawing on v rse side. Signed X Title: Date: I FO EPARTMENT USE ONLY / Application Accepted by _ Date_ f��Z^ Area Pit or Grout Inspection by Date Final Inspection by Date 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 FEE INFO 'AMOUNT DUE AMOUNT REMITTED CK R CEIVED BY DATE PERMIT"ND. « EH13.24(FIM I/NSI vd't 00 EH 1420 ll��/