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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) 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 vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ZZ. City Lot Size/Acreage Owner's Name Address, m ___ Phone { Contractorf.✓s Address" - i License No.a�____�.,r VPhone TYPE OF WELL/PUMP: _ _ NEW WELL ❑ WELL REPLACEMENT F1' -DESTRUCTION o Out of Service Nell ❑ monitors Well PUMP INSTALLA`TiON ❑ rSYSTEM REPAIR 71 �. OTHER ❑ � C7 DISTANCE TO NEAREST: SEPTIC TANK. - .r SEWER LINES ,%DiSPOSAVFLD. -.-_ PROP. LINE ti r �R�t .� s S "FOUNDATION "' AGRICULTURE_WELL� -" "''-OTHER WELL "" P)TS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTPEUCTION"S'PECIF..ICATIONS 1 ! 17 Industrial ❑ Open Bottom ❑ Manteca Diae of Well Excavation Dia. of Well Casing 177 Domestic/Private El Gravel Pack k X C3 Tracy Type of Casing_ \ :° 1 �� Specifications I'1 Public Cl Others Ywi 1 Delta4_ � Depth of Grout Seale I Type of"Grout 1 1 Irrigation Approx. Depth I I EasternSurface•Seal Installed"by 4 f Repair Work pone'-L7�--Type of-Pump H.P.. ---- �State Work-pone ^^� Well Destruction CJ Well Diameter Sealing Material & Depth t r Depth Filler]Naterial & Depth # TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is r available within 200 feet.) installation will serve:Residenc� � e=Commereial Other Number of living units: Number of bedrooms •. i I Character of soil to a depth of 3 feet: "- '^ ---------�-- _ __-"—_- Water table depth-- SEPTIC epth SEPTIC TANK. �p� Type/Mfg Capacity No. Compartments r PKG. TREATMENT PUT.'0 -....-...Method-of Disposal Distance to nearest: Well Foundation �`;_ Property Line LEACHING LINE ❑ No. & Length of.lines ..Total length/size t t,. ) e FILTER BED 1-11Distance to nearest: Well --�� Fdou tion_ Property Line I SEEPAGE PITS I II Depth a -- Size Number t SUMPS kt Distance�lo_nnearest: Weelll '; Founds on Property Line, S DISPOSAL PONDS 4� L7 ; r c�uca� I hereby certify that I-have prepated this a�plicao n an work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin�Cou ty ' i Home owner or licensed agent's signature certifies the following, "I'certify that in the performance l f the work o which thio permit is issued 1-shall riot employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting.signature f certifies the following-j"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to w6rkman's46mpensa- tion laws of California." The applica mu call for all required inspections. Complete drawing on reverse side. I a Signed X ' �°` Title: 1 _ _-__ Date':' R DEPARTMENT U Er LY Application Accepted by �.. Date Area Pit or Gious Inayection b. Data Final Inapectian by Ztedd. Date yZ- Additional Comments: s s ttt Applicant - Return all copies to: San Joaquin County Public HealthviServices -,,,,_- --------- &iidironmental Heafh Permit%Serces 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE :- AMOUNT REMITTED' t,*,� CK 01:EIVED BY DATE PERMIT'NO. • EK 13.24(REV.i i n e) £H t4.2a