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APPLICATIONrp ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (,,,209)468-3420 P O BOX 2009, STOCKTON, -CA 95201 _LA 5 f��-- rf 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�62 and_the Rules ations of San Joaquin County Public Health Services. A " 17-7, Job Address �� ` City Lot(JSiz'e/Acreage Owner's Name �� dress C P V_ Phone t Contractor Address j7� 7 �� f'•�cJ'oDr�L.icanse No. Phone oZ� U . _�__.__-� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia, of Well Casing 'N Domestic/Private ❑ Gravel Pack ❑ Tracy' Type of CasingT t Specifications i'1 Public 1.1 Other Cl Delta Depth of Grout Seal ' Type of Grout >Klrrigation -___Approx. Depth I Eastern Surface Sedi Installed by S Repair Work Done ❑ Type of Pump H.P. _ 3 --1 — State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth . Filler,Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I -AFPAIR1AOblTION I I DESTRUCTION I i INo septic system permitted if public sawer,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: k ` Water table depth SEPTIC TANK. 0 Type/Mfg w Capacity No. Compartments PKG. TREATMENT PLT. 0 „Method of Disposal Distance to nearest: Well Foundation Property Line V LEACHING LINE ❑ No. & Length of'lines Total length/size FILTER BED [_1 Distance to nearest: WeII Foundation Property Line SEEPAGE PITS 11 Depth Size T Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby cenify 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 applic ust ca or all required inspec' ns. Complete-drawing on rev side, o I Signed X Title: < �,f Date: T OR DEPARTMENT USE ONLY -� t ` Application Accepted by ' - - ---- Date t��-- Area ®1 +� Pit or Grout Inspection by Date Final Inspection by Date Z Additional tornments: V Applicant - Return all copies to: San Joaquin,.County,Public Health Services Environmental Healih Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE A UNT REMITTED K RECEIVED BY DATE PERMIT'NCA O. INFO e�EH 13.24IAEV.rEH a-2e 111A16-1;FY 4