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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 Regulations of San Joaquin County Public Health Services. Job Address / l " �1 1 �- City-,�J, 'Lot Size/Acreage Owner's Name �•��^�-�" Address abrt: Phone Contractor Address License No.L Phone TYPE OF WELL/ M NEW WELL ❑ WELL KEPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well �7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing K Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 11 Public 1-1 Other (-1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth 11 Eastern Surfn Installed by Repair Work Done Type of Pump lid, H.P. State W on - A„ Well Destruction ❑ Well Diameter Sealing Material & Depth ,Qar� Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I 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 O Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ MethcPAYMENT Distance to nearest: Well Foundation Property Limy CCE�IVE LEACHING LINE Cl No. & Length of lines Total length/size 11J H N1 9 1992 , FILTER BED ❑ Distance to nearest: Well Foundation Properg 99AQ N G UNITY PUBLIC HEAI TH SFRVIC:FS SEEPAGE PITS 11 Depth Size Number ENVIRONMENTAL HEALTH DIVISION SUMPS Ll Distance to nearest: Well Foundation Property Line 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 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,must 11 for all required inspections. Complete drawing on reverse side. Signed X l c t- Title: Date: FO EPARTMENT USE ONLY Application Accepted by Date ^2� �_ a Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 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 IF O AMOUNT DUE AMOUNT REMITTED CK N ECEIVED BY DATE PERMIT'NO. . EH 13.2 IREV.r i e sl �� t .� EH 14.26 f (.��