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APPLICATION �I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 . i P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES L 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. +, Job Address9 b !R City Lot Size/Acreage S F. Owner's Name Address -�r� Phone Contract o Addres License 463A! � Phone d56 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FI DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER D Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .T INTENDED USE 'rTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industr' ❑i Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Private ❑i Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public 1-1 Other n Delta Depth of Grout Seal Type of Grout t 1i Irrigation ip Approx. Depth I I Eastern Surface Seal Installed by N i' Repair Work Done i?- Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth d M TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is {� available within 200 feet.) Installation will serve: Residence Commercial= Other k Number of living units: L Number.of bedrooms Character of soil to a depth of 3 feet: „„ JMVrl"l h SEPt'IC TANK. ❑1 Type/Mfg Capacitys PKC,: TREATMENT PLT. ❑ s q r Sat Distance to nearest: Well Foundation Prop i - 11N COUNTY LEACHING LINE ❑ No. & L'engtli of lines TotaRWfikJEALTFf Ser,',cS FILTER BED'S. ❑ Distance to nearest: Well Foundation ENViRILV AL ti illYral i SEEPAGE PITS 11.I DepthSite Number' SUMPS 0:1 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, 1 shall not i employ any person in such manner as to become subject to'workman's compensation laws of California." Contractor's hiring or sub-contracting signature x Isnifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa, tion laws of California." I I The applicant mus all or all required inspections. Complete Brewing an reverse side. _ p. o Signed X_ _._,_f Title: Date: FOR DEPARTMENT USE ONLY II 6Application Accepted by Date g �`� Area j r Pit or Grout Inspection by �I Date Final Inspection by �(�sP.0 -_ Date Additional Comments: i Applicant - Return ��all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services i h IWi 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMi7-N0. E EH ie.mrRev.,,xa, fp ' 4S,,yfTz� Ll�c� . 3373" G"Z) / vZ�Zb�X0"Vi3==j ,. .: