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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL'•HEALTH DIVISION 445 N SAN JOAQUIN, iPHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES. ]. YEAR FROM DATE ISSUED r (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. 54 and 1862 and the Rules and Regulations of San Joaquin County Public Health Ser¢�}ces. g, ® ��J f fes!' 1 '�/� �� U + City ''r 1-o Lot Size/Acreage fJ " (Job Address _ k .& ,�j)) t,r f t t 7 �G°C Phone V`.!f`-''1 _ Address )(Owner's.Name ,Contractor _ � Address License No. Phone ' TYPE OF WELL/PUMP: :1. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring t>e11 C7 DISTANCE TO NEAREST: SEPTIC TANK 5E LINES ti 01 AL FLD. PROP. LINE - FOUNDATION AGRICU URE WELL! OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA C CTION SPECIFICATIONS ` ❑ industrial ❑ Open Bottom 0 Manteca ra i o 'all Excavation _ Dia. of Well Casing [I Domestic/Private ❑Gravel Pack Ll Tracy Type of to i g_ Specifications i'1 Public [1 Other n a Depth of Grout eel r Type of Grout r l I Irrigation T:Approx. Dep l I Eastern Surface Seai instal by Repair Work Done 0 Type of Pu H.P. to Work Done_ Sealing Material`&'"Depth 1 4 J Well Destruction ❑ Well Di ater 1 ; . � - ; Depth r �- Filler al &:Depth E TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR 4DDITIO ESTRUCTION 13 lNo septic system permitted if public sewer is i ; tavailable within 200 feet.l r` - .� f S Installation will serve: Residence Commercial_ 0[iler rPi k' t Number of living units; ., Number of bedrooms } # Character of soil to a depth of 3 feet: ' t I " Water-table depth r SEPTIC TANK )K .Type/Mfg �-�^ ry - Capacity- } 0 ..No.,Compartments PKG. TREATMENT PLT. ❑ ' + Method of Disposal w 't� Distance to nearest: Well Foundation Property Line . LEACHING LINE-'-- ❑ No. & Length of.Elines _ XIS "` "Tota!length/sire ! FILTER��BED ❑ Distance to nearest: Wel! Foundation a Property Line j T � � Size � - — Number SEEPAGE PITS? t rl'l Depth SUMPS Q LI .-Distance to nearest, Well Foundation Property Line`.. y ! DISPOSAL PONDS` ❑ hereby cortify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances;"state laws, and I rules and regulations of the San Joaquin County Home owner r li nsed agent's signature cenifies the following; "I certify that in the performance of the work for which this permit is issued, I shall not employ any rson in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub contracting signature" certifies the Ilowi g: " certify that i the performs ce of the work for which this permit is issued, I shall employ persons subject.to•workman:s compensa- tion laws of alit nis." =z} . The applic t call 1 e inspections Complete drawing on rev rse side. -, � )(Signed X Title: plr, Date: "7 te �� FO DEPARTMENT USE ONLY }" ' ` I Application Accepted by Date ` -"�b Ares.'c_, Pit or Grout Inspection by Date Final Inspection by ��r �� to Additional Comments: t _ - Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Sikn, CA 95201 � � t CK ill FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'.NO. INFO • EN 13-24 IREV.rin61 EH 11.26