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APPLICATION I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I� ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P 0 BOX 2009, STOCKTON, CA 95201 1. PERMIT EXPIRES 1 YEAR -FROM DATE ISSUED I� (Complete in Triplicate) .9 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 ec4liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Ser ces. ,I Job Address Il City Lot Size/Acreage t I� f � � Owner's Name9j, Address c 7—'— Phone I'` Contractor gj& Address dAt License No. Phone TYPE OF WELL/PUMP: it NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC,TANK =- SEWER LINES-!. -- ;,_.,,.DISPOSAL FLO. 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 C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-- Specifications_ I'I Public C7 Other ❑ Delta Depth of Grout Seal Type of Grout — Surface I Irrigation _ _��AppraK, Depth i I Eastern Surface Seal installed by Repair Work Done 10 Typt of Pump H.P. S t Work Well Destruction $L Well,!Diameter Sealing Material A Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is �1 available within 200 feet.) Installation will serve: Residence— Commercial 'Other Number of iivino units: �� Number of bedrooms AYMENT Charecter,Ofsoil to a depth of 3 feet: kzwgt r taWgi th SEPTIC,TANK 13 Type/Mfg Capacity ( �o��pomytpPLa}}h nts PKG. REATMENT PLT, ❑ Ii `Me6d o>TJposal Distance to nearest: Well Foundation LEACHING LINE L� No. & Length of`lines ota n ig l§iYti ;jAL` DIVi` iU FILTER BED _- , n Distance to nearest: Well Foundation Property Line �a SEEPAGE PITS l I Depih_ SireNumber a SUMPS L3 Distance to nearest: Well Foundation property Line ' - DISPOSAL PONDS 0 IA . 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 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 y 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." E The applicant all for II re inspections. Complete drawing on verse side. - E Signed X Title: Date: { FOR D ARTME USE ONLY Application Accepted by Date res Pit.or Grout Inspection by Date Final Inspection b Date t!p Additional Comments: i t Applicant - Return all'y copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFOFEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY D TE r . PERMIT'N0. • EH 13.24(REV.11 n sl EH 1/.1e f // �—