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. . .: ADPL ICATION R #A0 "esu SAN JOAQUIN COUNTY PUBLIC HEALTH 3ERS ENVIRONMENTAL HEALTH D I V I S`I 1 445 N SAN JOAQUIN, PHONE (209)4 - P O. BOX 2009, STOCKTON, CA 9 , f PERMIT EXPIRES 1 YEAR FROM DATEI (Complete in Triplicate) Application is hereby Stade 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. Q 0 Job Address v City Lot Size/Acreage Owner's Name laL�ddress', Phone/ 7 Contractor Address icense~No. Phone r TYPE OF W LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 f l Domestic/Privater I Pack ❑ Tracy Type of Casing- Specifications } I'1 Public ,��W n Delta Depth of Grout Seal Type of Grout I I IrrigationIF/'��.'Wsaox. Depth I I Eastern Surface Seal Installed by 1 Repair Work Done pey0t; mp H.P. ___ State Work Done _ �� Sealing Material & Depth I Well Destruction"1~ ❑ `z ell Qi;�tpsf _ _ _ - { AQ^ tJ1Qv1 ' Filler Material ptti r TYPE OF S I N I I REPAIR/ADDITION ( DESTRUCTION I 1 INo septic system permitted if public sewer is Jj w1 t4JNL - available within 200 feet.) Installs ' 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 T t ype/Mfg Capacity'__ ! No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation I Property,Line LEACHING LINE 0 No. & Length of lines - otal length/size - FILTER BED Cl Distance to nearest: Well/ Foundation Property Line 6a _. SEEPAGE PITS. 11 Depth Size Number SUMPS LI Distance to nearest: Well DD 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 cortify 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." _ - �• .r'?�""r - I The applicant must call for all req . d inspections. Co plate drawing on,reverse,side. --; OLIZ Signed Title: r! Date: / FOR DEPARTMENT USE ONLY CApplication Accepted by eDate Th / Area j ,Pit/or Grout Inspection b Dat Final Ins ction b �.•O�i Date ( 1 Pe Y pe Y --- Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services e ' Environmental Health Permit/Services r'1 , 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. 13 �-p, CASH' �q„n`� EH 13.24,1REV.%inat. D,f�® ,�`� �� 6 EH 14.20 'V