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APPLICATION d Ff SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION A r4 445 N SAN JOAQUIN, PHONE (209)468-3420 RFC EN]` P O BOX 2009, STOCKTON, CA 95201 SgNOp ?sIVP PERMIT EXPIRES 1 YEAR FROM DATE ISS pUQLICH QU/N 1% (Complete in Triplicate) ON'C 'A / o,�on-), lye �6kjll Application is hereby made.to San Joaquin County for a Permit to construct and/or install the work herein �slyr� � This application Is made in coMliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Re latio ian Joaquin County Public He th S ices. Job Address 4City Lot Size/Acreage Owner's Name Address ' a46�— n�• �� Phone ConlraClor Address A, License No.1atQ�_(�r Phone TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT R DESTRUCTION D out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications I"I Public Cl 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 LJ Type of Pump H.P. ; State Work Dbne Well Destruction ❑ Well Diameter _ Sealing Material b Depth -� t Depth ;k B f Filler Material. i Depth l TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/AODIITION I i DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.) Installation will serve, Rssidenc4_ Commercial—, Other_ Number of living units: (Number of bedrooms J Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Typei Mfg Capacity No. Corn arfrnents PKG. TREATMENT PL's. 0 � � � Method of Disposal T�11 Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines _ Notal length/size I FILTER BED ❑ Distance to nearest: Well Foundation Property Line k r„ SEEPAGE PITS 11 Depth Size _ Number `. SUMPS UI Distance to nearest: Well Foundati6n: Property Line DISPOSAL PONDS ❑ I hereby certify that I hive 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 fotlo n "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 l The applica call'for all req it d insPect s. Complete drawi� r v rse side. Signed Title. Date: t 199 DEPA Y t F } Application Accepted by Date Area i Pit or Grout Inspection by Date Final Inspection by Date i 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO. • EH17�•2a 3-24 1 R EY.r i n s EH � � a .S.dE? f^��