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^� APPLICATION 4 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 Ls madeiliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations f San Joaquin Co c th Services. AC Job Address '�+ E "� s('� City Lot Size/Acreage / Address �,` � Phone!'3 2 fA- Owner's Name , Contractor �ipvs`t Address ' e O License NO3?7*7'p5 Phone �T TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES DISPOSAL FLD. ISS' PROP. LINE 140 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 16 n Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing Y O -i-;iXiomestic/Private >�:Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public / (a Other n Delta Depth of Grout Seal 1—� Type of Grout CCitn_c�_ I I Irrigation 3��.Approx. DepthS IIE stern Surface Seal Installed by Repair Work Done U Type of Pump H.P. 3 _-- State Work Done _ tic 'r Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/,size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that 1 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, 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 compensa- tion laws of California." The applicant muig call all ad inspections. Complete drawing on reverse side. �/ q Signed X Title: 0WA"4k Date: DEPARTMENT USE ONLY Application Accepted by ��`� Date 2, Area Aidt w, Pit o Grou spection byDate T� Final Inspection by Dat •S /2 43 Additional Comments: 1 f �+.ta Applicant - Return all copies town o quin unty Public Health Services �� /.3 ' GlctwtS..tTcF►- �� p� � Environmental Health Permit/Services j�l� do-,- 6dL✓'J 1�/ 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 •0 >_ 1. �y FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. c.�r �S; rN CASH - EH 13.24(REV.1ins) .W:) ^1 IL42 W-i3 4,3 �1 EH II•Ia t c ��