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APPLICATION l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,. PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 . PERMIT EXPIRES 1 YEAR FROM DATE ISSUID (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 =o City Lot,Size/Acreage Owner's,Name• i1 � Address --J17/r ,' "Phone Lel Contractor Address// '�1/��+�- r cense Noi� 6 Ph,on `, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ 1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 I [7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I 1 Public is Other [-1 Delta Depth of Grout Seal Type of Grout 11 Irrigation Approx. 'Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ I Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: ,rNEW INSTALLATION I-1 REPAIR/AD DITION DESTRUCTION I1 (No septic system permitted if public sewer is Q available within 206 feet.) Installation will serve: Residence y Commercial Other Number of living units: _Z— Number//of b�e,drooms Che►acter of soil to a depth of 3 feet: fes,:/ Water table depth SEPTIC TANK.EN6T-0 Type/Mfg Capacity No. Compartments Metho PKG. TREATMENT PLT. ❑ Distance to nearest: Well, ;Foundation Property Line of Disposal i LEACHING LINE No. & Length of lines Total length/size j FILTER 13ED ❑ Distance„to nearest: Well �d Foundation Property Line i SEEPAGE PITS Depth 4��L� 'o5ize Number SUMPS LI Distancii�6 nearest. Well �` Foundation . .. '. _�•-�— Property Line r 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required i s 'ons. Comple, drawing on reverse side. Si ne = Title:.t V lG' Date: C� ��—_ . i FOR DEPARTMENT USE ONLY / Application Accepted by e--cn+� Date /1A/ " / Area Pit or Grout Inspection by G Date Final Final Insppection by %- Date lex Additional Comments: Ply ��/�1 � - Ct !/r1��i`� Applicant - Return all copies to: SanlJoaqui-n County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009,-Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. . EH 13.241REV. EH 1425 /! !