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APPLICATION PAYMENT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED 445 ENVIRONMENTAL ANJN PHONE (209)468-3420 TH AUG 10 1c"3 P 0 BOX 2009, STOCKTON, CA 95201 SAN jOAQUIN CI'yAWY PUBLIC HEALTH SERVICES PERMIT EXPIRES 1 'YEAR FROM DATE ISSUM ENVIRONMENTAL HCA4THDIViSICA (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 1962 and the Rules and Regulations of San Joaquin County Public Health Services. as( /1 r h IP !! City,��_—_ Lot Size/Acreege �'~o V o Job Address to Owners Name `_lt• Address .-�S G *1` e&A Phone Contractor rS=A Z ddress V- U>uzu S JdaJ License No. (03438 Phone MIS SG- NEW WELL 18L WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well U X A UMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ti,�,Monitorfng Well N � Nl, DISPOSAL FLO. -- PROP. so"x1O T; SEPTIC TANK �,�►A SEWER LINES ._. - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation �fy�t Dia. of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications..� 1'1 Public n Other fl Delta Depth of Grout Seal _ 'ask (f Type of Grout — l I Irrigation Apprax, Depth 1 I Eastern Surface Seal Installed bycwc=o!J SaMptzNG Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth CEmYL TGyocl'C x Mo+axTrtiR. 1C,5>.�p�s0epth s /0' _ Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I !No septic system permitted if public sawer is available within 200 feet.) 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 FM SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L! Distance to nearest: Well Foundation Property Line DISPOSAL PONOS ❑ 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, ! shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 call for all required inspections. Complete drawing on reverse side. Signed Tide: id/ -- �S C L 06 75� Date: 4 FOR DEPARTMENT USE ONLY Application Accepted by ' Oate3111113 Area Pit or Grout inspection by Date (3 r Final inspection by " ' Onto +� Addhional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Bnvironmental Health Permit/Services 945 , San Joaquin, P O Box 2009, Stkn, CA 95201 FEEAMOUNT DUE AMOUNT REMtTTEO CK RECEIVED BY DATE PERmrr'NO. INFO CASH . EM.13.24[REV.I,N51 i 13` s 1 Ek t11-7a