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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) a Application is hereby rade.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in couplia.nce with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. ``//''__..'' Job Address �� II*d City �c`1 Lot Size/Acre age Owner's Name �� k4l-gddress f I Phone 2— Contractor SLA T" Address,10n ICI License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service well ❑ = j PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing_ Specifications I'1 Public �i-1 Other F1 Delta Depth of Grout Seal Type of Grout — I I Irrigation _ Approx. Depth I I Eastern Surface Seal installed by Repair Work Done 0 Type of Pump H.P. State Work Done Wel! Destruction ❑ Welt Diameter Sealing Material & Depth r Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION lNo septic system permitted if public sower is 1 available within 200 feetJ n 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 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ x - -- Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No, & Length of linesTota! length/size z\(x FILTER BED ❑ Distance to nearest. Well Foundation # Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation ___- Property Line DISPOSAL PONDS ❑ T' I hereby certify that 1 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 i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 mu call for all require pections. Complete drawing on reverse side. Sin " g Title: Date: F R PARTMENT USE ONLY Application Accepted by + Date Area Pit or Grout inspection by .Date Final Inspection by Datej Additional Comments: w • 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 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY ` INFO ��777 ATE PEAMI7'NO. . EH 13,24(HEV.+i w 5) f / s� ! EH 14.211 / / �►