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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEFLS%#RX."_ ENVIRONMENTAL HEALTH DSV �� i 445 N SAN JOAQUIN PHONE (2�AA P 0 BOX 2009, STOCKTON, CS'R62#1 I!EMIT EXPIRES 1 YEAR FROM D T SUED (Complete in Triplicate Application is hereby made to San Joaquin county-for a permit to construct and/or install the vor herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 an the s a=d Regulations of San Joaquin County Public Health Services. Job Address 7 "' City Lot S ze/Acreage Owner's Name �� Address Phone / 7 [ MM Contractor �Tg dress �I Lice /e/o.JL_��Phone 4el.21011 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA hit N f n ESTRUCTION O.Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM R R Q OTHER M Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP SAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OT ER WELL PS INTENDED USE TYPE OF WELL PROBLEM AREA CONST I P CIFiCATIONS NU C1 Industrial ❑ Olsen Bottom ❑ Manteca Dia. of all cav ion �� fl!af'4Vf!lt�f•Casing f7 Domestic/Private 0 Gravel Pack ❑ Tracy Typ of sing 4149us I'i Public [I Other F1 Delta Dep of Grout eal Q(IiM@09W I I Irrigation —.Approx. Depth I I Eastern Surfa out nstalled by PUBLIC HEALTH SERVICES _• _�_ Repair Work Done L] Type of Pump H.P. Stat�WJPb8 NTAL HEALTH DIVISION Well Destruction 0 Well Diameter Se Ing tori & Depth Depth _7 le Mater) 4 Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I REPAIR/ADDI N I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Resi once! Commercial er Number of living units: Number of bedrooms So� �\_ / Character of soil to a depth of 3 feat; Water table depth SEPTIC TANK 0 TypelMfg Capacity No. Compartments PKG. TREATMENT PLT.D Method of Disposal Distance tont: elt Foundation Property Line LEACHING LINE 0 No. 8 Length of nes Total length/size FILTER BED ❑ Distance to near at. We 1 QQ _ Foundation Property Line SEEPAGE PITS 11 Depth &K IPA +t its Number MOPS LI Distance to nearest: Well Foundation -!J Property Line !'� DISPOSAL PONDS ❑ I hereby certify that l have prepared this applicat10 and that the work will be done in accordance with San Joaquin county ordinances, stela laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenif a the following; "I certify that in the performance of the work for which this permit is issued, I shah not employ any person in such manner as to bee subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the following:"I certify that in the pe mance of the work for which this permit is issued,l shall employ persons subject to workman's compensa tion laws of California." The applicant must call for all r u ed ins , Bons Complete drawing on reverse side. rq- Signed Title: �/l/ 1/ -_-- -- Date: FOR DEPARTMENT USE ONLY M Application Accepted by -- _ Date � � � � Area Z' Pit or Grout I S `w rns�a lG�a ✓� Inspection by Date Final Inspection by- - -- - - - —�rZ Date Additional Comments; r ' Applicant - Return all copies to: San Joaquin County Public Health Services CTh 3 y J7(C Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. 1 INFO CASH