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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 .ln--,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. 1 Job Address �. CNA� City I-- 'ts-- Lot Size/Acreage Owner's Name Address Contractor Address License No. f- Phone - 3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca T Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack n Tracy Type of Casing_ Specifications I'I Public El Other fl Delta Depth of Grout Seal Type of Grout � I I Irrioation —,Approx. Depth I 1 Eastern Surface Seal installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material fr Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION hF REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence-.,A- Commercial 0th r L Number of living units: __LJ_ of bedroo (n Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. a Type/Mfg. Capacity142OL2 No. Compartments � I PKG, TREATMENT PLT, Cl Method of Disposal r Distance to nearest: Well 1; Foundation 1D f Property Line �Sr LEACHING LINE > No. b Length of tines -' Total length/size -- FILTER BED ❑ Distance to nearest: WellIl`:J Foundation _ �j(�T� Property Line SEEPAGE PITS t7epth rSize r r umber L (� SUMPS Distance to nearest: Well 10-51 Foundation Property Line Z,a(fid/a DISPOSAL PONDS ❑ 3✓yc�.tY'� 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, an� 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,.!shall employ-persons subject to workman's compensa- tion laws of California." The applicant must all for all r r d inspections. Complete drawing on reverse side. Signed X � 'f �_ Title: m- -------- -- -_ Date: ENT USE ONLY Ap li ation Accepted by Date y 1f� Area d� r or Grout Inapaction by "` Date �� `F' L-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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASHCy if RECEIVED BY DATE PERMIT'NO. . EEH 14-Mp M 17.2 IREV. /ns�SIV 0 ` c i> J�6