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APPLICATION + SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION No 3 Ly 445 N SAN JOAQUIN, PHONE (209)468-3420 I P 0 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 Regulations of.�San Joaquin County Public Health.Services. !s Job Address s(1 `o City_ GG1� Lot Size/Acreage Owner's Name Address 1 �� i Phone k Contractor Address License No. Phone YPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well. ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well t DISTANCE TO NEAREST: SEPTIC TANK = SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONS AGRICULTURE WELL- = OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1-1 Other F1 Delta Depth of Grout-Seal Type of Grout—4 I I irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth !; DepthFiller Material-&'Depth- I ` TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION INo septic system permitted if public sewer Is ailable within 200 feet.l 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 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: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number k SUMPS LI Distance to nearest: Well Foundation Property Line I, DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in,.accordancs with San Joaquin county ordinances, state laws, and rules and regulations of-the San Joaquin County ..._- ', s. } Home owner'or licensed agent's'signature certifies the.IoNowing: "1 certify that in the;performance of the work for which this permit is issued, I'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 cc mpensa- tion laws of California." The:pplica ust tail for all required inspections. Complete drawing on reverse side. �find Title: � �� _ Date:'- Q " a R ARTMENT USE ONLY 9 pplication Accepted by Date �� ` Area 't Pit or Grout Inspection by .Date Final Inspection b Date St Additional Comments: } Applicant - Return-all copies to: San Joaquin County Public Health Services Eavironmental 'Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 M K t FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO I 7 EH 13-24IREY.1/N5 I ��. t..�� - �• I,� Ek 14.25 � I