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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 ESPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 't 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. r Job Address ,,,,, �'��Ps► City Lot Size/Acreage Owner's Name Address Phone Contractor ass cense No/ Phone TYPE OF WELL/PUMP: NEW LL ❑ WELL REPLACEMENT Cl DESTRUCTION 0 Out of service Weli ❑ 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 Dia. of Well Excavation Dia. of Well Casing 177 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public El Other ❑ Delta Depth of Grout Seal Type of Grout C� I I Irrigation _ Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. __ State Work Done _ Well Destruction ❑ Well Diameter —Sealf Mater1al73--Depth Depth Filler Material d Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR IADDITIONA DESTI,UCTION I i INo septic system permitted if public sewer is L � available within 200 feet,} Installation will serve: Residence! Commercial_ Other . Number of living units: __�_ Number of b oms .J I Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ /' Method of i I Distance to nearest: Well Foundation 7` Property Line LEACHING LINE C1 No. ✓k Length of lines Total length/size FILTER BED n Distance to nearest: Well 1.Foundation Property Line . I SEEPAGE PITS I I Size Depth Number t P _ _- SUMPS LI Distance to nearest: WeII i Foundation Property Line f DISPOSAL PONDS ❑ 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 j 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 laws of California." / The opplic's ir uir d ' s ctions. Co I rawing onr arae side, Signed Title: -- . -- .._ Data: f F R DEPARTMENT USE ONLY ��]],, f► 61-10 -v' ,�1 Application Accepted by / Date 4 J Area �_l 14 -1 V Pit or Grout Inspection by ^ Date Final Inspection b Date Additional Comments: j Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 4545 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE - AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT'NO. EH 13-24• EH 11-2a[REV.I/As) �,/} p i? `C� r J b 1 -c-) 1P�