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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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatione of San Joaquin County Public Health services. Ll 45 G/f"'�^� City� Lot Size/Acreage `-=� �r`�" —✓ I Job Address �a ct`a i / )" Address4 Phone ea Owner's Name dre s Contractor fcly a A )cense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT,{') DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _— Dia. of Weil Casing El Domestic/Private 0 Gravel Pack Ll Tracy Type of Casing_ Specifications Il Public [I Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _ _ Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done ' L7 Type of Pump H.P. -- State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 14 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDtTl0N DESTRUCTION I I (No septic system permitted if public sewer 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 SEPTIC TANK ❑ Type/Mfg L Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines _ Total lengthlsize 't FILTER BED 0 Distance to nearest: Welt QO Foundation Property Line i SEEPAGE PITS 11 Depth Size �� W` ' Number f9✓_'� _�Zo�/�� o� S P Ll Distance to nearest: Well, ..,� Foundation Property Line 1 DISPOSAL PONDS ❑ ,LJy��JI 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, f 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 compsnsa•-� tion laws of California." r The applicant must call for squired i spections. Complete drawing on reverse side. Signed X Title: (.)1Q�� Date: Q FOR DEPARTMENT USE ONLY Application Accepted by nate Area Pit or Grout Inspection by Date .Final Inspection b Date f Additional Comments: eAr OV — Applicant -- Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P Box 2009, Stkn, CA 95201 FEE I AMOUNT DUE MOUNT REMITTE RECEIVED BY DATE PERMIT'NO. INFO CASH . EM 13.240111V. EN 14.20 }