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APPLICATION FOR PFRI&IT SAN JOAQCIN COilNTPUBLICAL,�iDIVISION ALTH VICTS ENVIRON1dENT STO1i CA 95201 P O SOS 2009 , STOC �� (209) 468--34-4''7 3 Y R (Complete iii Triplicate) This ' vork in made to Saa Joaqula County for a permit to construct and/or s/o instal1862 and thaeRules and eRegulations dof Ban Application is hereby 1lance with San Joaquin County Ordinance .Ho. 5 4 application is merle in carrap Joaquin County Public Health services. Lot gime/Acreage i Cit 8 a ' e _ �ob Address G Phone ddress `5 xOwrner's Name Phone License No. _.�------ OESTRUC7ION i1 Out of Sar Address well Gl Address 0" Seoring well &OntiactOr NEW WELL ❑ WELL REPLACEMENT F OTHER ❑ TYPE OF WELLIPU P. SYSTEM REPAIR pAOP. LINE PUMP INSTALLATION ❑ DISPOSAL FLD.---� PITSISUMPS �— SEWER LINES --------��` OTHER WELL DISTANCE TO NEAREST: SEPTIC TANK --•--- AGRICULTURE WELL FOUNDATIONIFICATION ��— PROBLEM AREA CONSTRUCTION SPECDia of Well Casing TYPE OF WELL Dia, of Well Excavation Specifications 1 INTENDED USE. ❑ Open Bottom ❑ Manteca Cl industrial ❑ Tracy Type of Casing Type of Grout -------- CJ DomesticIPrivate ❑ Gravel Pack Depth of Grout Seal 1-1 Other ❑ Delta (� [ M Public .� Apprax, Depth ❑ Eastern Surface Saul Installed by �} 1 Cl IrriUation State Work Done H.P. i Repair Work Done L3 Type of Pump --�— Staling Material i Depth Weil Destruction O Well Diameter -- Filler Tfaterial Depth lic system permitted if public sewer is DeptTYPE OF SEPTIC WORK: NEW 1NSTALLATiON O REPAIR/ADDITION LZ DESTRUCTION ClG availabi within 200 feet.l 1 Commercial— Other�-- inaaNatipn wiA serve: Residence — h Number of living units: Water table dept Number of bedrooms _� No. Compartments of soil to a depth of 3 feet: CapacitY----�"—` Method of Disposal SEPTIC TANK ❑ Type/Mfg Property Line PKG, TREATMENT PLT, Q Foundation._----- _.. I Distance to nearest: Well �--- Total length/size k LEACHING LINE ❑ No. & Length of lines Foundation FILTER BED ��--- Property Line �_---- C'I Distance to nearest: Well —Y--"— Size Number l SEEPAGE PITS i l Depth Foundation Property Line SUMPS ��----- 1 LI Distance to nearest: Well 4 DISPOSAL PONDS 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, a d rules and regulations of the San Jonaturre County certifies the following: ,I certify that in the performance of the work for which this permit o issued, I shall not Home owner or licensed agent's sig work for which this permit is issued, l shall employ persons subject to workman's compensa t an raon in such manner as to become subject tohweorkman's compensation laws of California." Contractor's hiring or subcontracting signature employ Y Pe certifies the following; "1 certify that in the performance o I laws of California." �'/ applicant must tali for ell required inspections. Complete drawing on reverse side. Date: The app " Tit[e: Signed 1(D' } FOR DEPARTMENT USE ONLY Date _.,. Area i Application Accepted by Date Final Inspection by r Date�-- pit or Grout Inspection by Additional Comrt+ants: A5� l Applicant Return all copies to: ENVIRONMENTALCOUNTY PUBLIC HEALTH JOAQUIN HEALTHDIVISIONPERMIT/SERVICES 445 N SAN JOAQUIN, p 0 BOX 2009, STOCKTON, CA 95201 GK RECEIVED By DATE PERMIT,NO. FEE AMOUNT DUE A UNT REMITTED CASH q q1 INFO �r-�� I i 4— . p„t374 IREV.i r�sI EH A-26