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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 f PERMIT E%PIRES 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. f_ Job Address ! A e-" City a 01 Lot Size/Acreage l Owner's Name O-P) d /V. 12R AddressPhone -3 Contractor /7 0"Q Address License N6,' � phone TYPE OF WE NEW WELL ❑ WELL'REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Stell ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR_Ll OTHER ❑ Monitoring Well ❑ I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS [I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Q C] Domestic/Private ❑ Gravel Pack ❑ Tracy 7 Type of Casing_ Specifications I'I Public M Other f 1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l I Eastern Surface Sedi Installed by Repair Work Done ❑ 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 'REPAIRJADDITION I I DESTRUCT IO (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence__ Commercial_ Otlier Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg C tr Capacity �3 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i - Distance to nearest: Well 20() Foundation 2c'�„ Property-Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 Horne 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 applicant must call for all required inspections. Complete drawing on reverse side. {. Signed ` O�^ 2.1.k-tile Title: W� Date: ` R D RTME LI5E ONLY Application Accepted by Dare Are Pit or Grout inspection by Date Final Inspection by Dat Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEI I p BY AT PERMIT'NO. INFO h C • EM 17-2/[REV.rinse r j`�d m r EH 11-20 L!