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APPLICATION'FOR PERMIT EIVE; D STAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE - I ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 SEP 2 5 1g � P O BOX 2009, STOCgTON, CA 95201 JNVIRONMEN AL HEALTH lERMIT EXPIRES 1 YFAR FROM DATE ISSU PERMIT/SERVICES ��00 (CAmplete in Triplicate) Application is hereby made to Joaquin Coun y forfoa 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 He th Services. Job Address I2ity �.o'c�� - Lot size/Acreage Owner's Name; Address ��OS Phone Contractor L Address License N1. �Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well [] DISTANCE TO-NEAREST: SEPTIC TANK SEWER LINES J41SPOSAL FLO. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1:1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications {Public Cl Ether„ -11 F1 Delta Depth of Grout Seal Type of Grout I I lfrigation I t Ap- 3X Depth I I Easigm Surfa a Seal installed by Repair Work Odne L3 Type of sump.t P — --- State Work Done Well Destruction O Wali Diameter ��----- Sealing material L Depth = : Depth! 3-n-'fir Piller Material i Depth TYPE OF SEPTIC WORK: NEW.INSTALLATION I 1 REPAIR/ADDITION I I- DESTRUCTION I I (No septic system permitted if public Bawer is available within 200 feel.I Installation will sews: Residence!�I Commercial ?Other Number of living units: Numberof';5adrooms Character of soil to a depth of 3 test:,- SEPTIC eet SEPTIC TANK. O TV-pa/Mfg" y 9 Capacity No. Compartments PKG. TREATMENT PLT.❑ i a. ►'Method off'Disposal s / _ Distance to-nearest: Well Foundation Property Line I \ LEACHING LINE 0 No. & Length of lines length/size i l� FILTER BED -�' ° O Oistarice to nearest: Well Foundation Property Line - SEEPAGE PITS.' I I Depth IN, Size Number SUMPS I ✓,,'� 1 Distanca-to nearest: ,,Well..-.- + Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have preps.red thin application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the Safe Joaquin County Home owner or!licansed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pertl0 'n such manner as to'become subject to workman's compensation laws of California." Contrector's hiring or sub-contracting signature certifies t%MIND i : "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 r is... 4.. The applic call for all roqu' inspection . omplete drawing on roverside. 3 Signed # Title: NlaData: € c FOR EPA TME USE ONLY /; 3 Application Accepted by + Date 2 Area I' ' Pit or Grout Inspection by Date Final Inspection by Date ! Q� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services r i e I Environmental Health Permit/Services r r I 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE Ir AMOUNT REMITTED C K EIVED TE PERMIT'NO. INFO y/ . EH t]-74IIIEV.Vie BI (� < 7 EH 14.1e