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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 !` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is hereby mMde.to San Joaquin County for a permit to construct and/or install the work herein described. This i application is made in cmWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. A City Lot Size/Acreage Job Address Address Phone !I Owner's Name Phone Contractor I,S -� Address ©`� J '• License No. ` TYPE OF WELL/PUMP: NEW WELL ❑• WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINEii D FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing l .-.- C7 Industrial C3 Ope i t"I`tl Type of Casing— Specifications I Cl Domestic/Private LI Gravel Pack ❑ Tracy Yp 9 p 1'I Public C7 Other (Z Delta Depth of Grout Seal Type of Grout l� I I Irrigation __ Approx, Depth I I Eastern Surface Seal Installed by f Repair Work Done 0 Type of Pump _ H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION k availablelNo thin system m treated if public sewetais Installation will serve: Residence.,]C_ Commercial — Other t Number of living units: -�— Number of bedrooms t 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 f d Distance to nearest: Well Foundation Property Line LEACHING LINE i1 No. & Length of Itnes Total length/size.i.. FILTER BED n Distance to nearest: Well Foundation Property Line f /� ) SEEPAGE PITS 11 Depth Size Number E �/ SUMPS LI Distance to nearest: Well Foundation Property Line A. 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, and rules and regulations of the San Joaquin CountyI Home owner or licensed agent's signature cenifies the following: "I 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 t certifies the following: "I Certify that in the performance of the work fol which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." - T. I - The applica a I t �,,,quwod in ctions, Complete drawing an reverse side. i Signed x - — Title: Oats: /�� OR �RTMENT USE ONLY f / h Application Accepted by Data/ Area I Pit or Grout Inspection b Date Final Inspection b Oatgln 1 Additional Comments: ;k Applicant - Return all coPies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 f FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y GATE PERMIT'N0. INFO /�,�( '/�jy� So �,. EH 13-24!REV.iin5i S� 7 lJv ! / ' i `�r✓ / OrV �/ • / ?