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APPLICATION SAN JOAQUIN,wCOUNTY PUBLIC HEALTH SERVICES ENVIHONMENTAL, HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 00'4 1 �_O PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Z- - (Complete in Triplicate) 06 .Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This ' application in made in compliance with San JoaquinTCounty Ordinance No. 54 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Cir Lot Size/Acreage Owner'a Name a Address Phone a Contractor Addressicense�No-- TYPE OF WELL/PU NEW WEL7� WELL REPLACEMENT In DESTRUCTION ❑ Out of Service well, ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK yl`_ SEWER LINES � DISPOSAL FLD. � PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS_/SUMPS # INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Is 1 n Industrial Open Bottom 0 Manteca Dia. of Well Excavation 'r Dia. of Well Casing � r fa Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications Il Public Ia Other f I Delta Depth of Grout jSeal T pe of Grout rigation —Approx. Depth i I I Eastern Surface Seul Installed by - Repair_Work Done U Type of Pump H.P. State Work Done WeU Destruction' ❑ Well Diameter Sealing Material i Depth - Filler Material A Depth Depth � •` i E TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic sysfent permitted if public sewer is available within 200 feet.) h f` installation will serve: Residence— Commercial— .Other ry' L ,Number of living units: Number of bedrooms F,v Character of soil to a depth of 3 feet: Water table depth '� 4 SEPTIC TANK Cl Type/Mfg ' spacity No. Compartments-. r y PKG. TREATMENT PLT. ❑ Method of Disposal 1 _ Distance to nearest: Well Foundation Property Line _ LEACHING LINE Cl No. & Leng�1* Total length/sizeFILTER BED CI Distance toWell Foundationy Property Line t � SEEPAGE PITS I I D Size Number SUMPS LI istance to nearest: Well Foundation Property Line '°,DISPOSAL PONDS ❑ I hereby certify that i have prepared this application and that the work,will e.done_in.accordance-with-San-�Joaquin-county-ordinances;�statd-law�;_and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: '4*certify that'in the pefformance of the work for which this permit is issued, 1 shall not a�� employ any person in such manner as to become subject toworkmen;-$compensation laws of California." Contractor's hiring or sub-contracting signature cenifies the folio ing: "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 C or a." � - The applican :;o:rallre;q�ugitiinspect• mplate drawing on averse side. gned X~ Title: _ r100'0 Date: 3 ) aFOYARTMENT USE ONLYApplication Accepted by ,�C-"^r � �,�� Rate ~�3_93 Area Z Pit or�irqut Inspection by 4.3 Final inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental. Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH t3•24 rREv. i n si Eli E n� q tt-2a 'r