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APPL I CAT ION /V D SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f ENVIRONMENTAL HEALTH DIVISION No 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 EXPIRESPERMIT YEAR (Complete in Triplicate) Application is hereby made to $&*.Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Son Joaquin County Ordinance No. 549 a6d.1$62 and the Rules and Regulations of San Joaquin County Public Health 8e es. � -� � ^�'� —' •`'`,` �1 / -- Lot Size/Acreage Job Address City Owner's Name4�� Address Phone t Contractor Address , license No. Phone YPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST; SEPTIC TANK � _ SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C.1 industrial ❑ Open Bottom ❑ Manteca Oia..of-Well Excavation Dia. of Well Casing FI Domestic/Private ❑ Gravel Pack 'I'1 Tracy ' Type of Casing_.,_ �. Specifications 1'I Public is Other T1 Delta Depth of Grout Seal Type of Grout I I Irrigation �.. Approx. Depth I I Eastern Surface Seul'Installed by Repair Work Hone L3 Type of Pump _ H.P, State Wdrk Done _ Ii Well Destruction 0 Well Diameter _ sealing Material i Depth l Depth Filler Material k Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR IADWTION i.I DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet,) i Installation will serve: Residence Commercial— Other 4 Number of living units: Number of bedroorAs Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Cl Type/Mfg" 'Capacity. No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation" Property Line � LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 11 Distance to nearest: Wall Foundation Property Line ' a SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest; Well Foundation. Property Line r DISPOSAL PONDS ❑ I 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 pertormance-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 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 alifornla." y The app can must ball for equirod irmpqctions. Complete drawing on reverse side, II gnod X Title: ._m 0'P--' Date: \\ OR DEPARTMENT USE ONLY C Application Accepted by rA A Date - � roa b�— Plt or Grout Inspection by Date Final Inspection by J Date Additional Comments: Applicant - Return all copies to: San Joaquin Count blit Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 85201 FEE INFO AMOUNT DUE AMORJUNT REMITTEO CASH IVSD 9Y DAY PERMIT'NO, EH137�IREV,riniY EH 14.�e