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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i1� �ID ENVIRONMENTAL HEALTH DIVISION `'� 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 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 1862 and the Rules and Regulations of San Joaquin County' Public Health Services. City 7/� P Cit �1 Lot Size/Acreage Job Address , / Owner's Name L' Address Phone Contractor ' / - '/} Address No." Phone TYPE OF WELL/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 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 C1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I"I Public 1.1 Other n Delta Depth of Grout Seal Type of Grout ^ I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by �/ Repair Work Done U Type of Pump H.P. __-- State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LL—IIESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence t-l' Commercial_ ther d Number of living units: _:�!= Number of b o s , Character of soil to a depth of 3 feet: li Water table depth SEPTIC TANK O Type/Mfg �— Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE LS-11—o & Length of lines Total length/size FILTER BED ❑ Distance to nearest: ell Foundation c7 f Property Line _ SEEPAGE PITS ILI►-t5epth D, fl Size Nu7ber _ SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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, I shall employ persons subject to workman's compensa- tion slifornia." The applicant Kcal,for a requi dlincti:7o lets drawing on r @rse side. J St Title: h�'1 ��►.[` \y Date: FO ARTMENT USE ONLY Application Accepted by Data AArea Pit or Grout Inspection by Date Final Inspection by Date 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 EE INFO AMOUNT DUE AMOUNT REMITTED CK 11 1 CASH RECEIVED BY DATE PERMIT'NO. . EH 13.21(REV.r M 51 /�