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APPLICATION A�p0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 C� 70 P 0 BOX 2009, STOCKTON, CA 95201 :,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �l (Complete in Triplicate) _.._ Application in 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. V Job Address � r/ dl City Lot Size/Acreage Owner's Names Address Phone !;� / _209 � f� ! , - Lontractor Ci- w—e- Pr�,l Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well C7 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 El Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_ Specifications Il Public El Other r n Delta Depth of Grout Seal Type of Grout I I Irrigalion ,_._,.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. _ _ State Work Done Well Destruction ❑ Well Diameter Sealing Material-& Depth Depth •+-- Filler Materiai & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I,I REPAIR/ADDITION I I DESTRUCTION No septic system pe d it public sewer is I a No, wit ' feet.l Installatto ' serve: Residence— Commercial— Other Number of living urn Number of bedrooms Character of soil to a depth of _ Water table depth SEPTIC TANK ❑ Type/Mfg opacity �No. Compartments PKG, TREATMENT PLT. ❑ '"' Method of Disposal Distance to nearest:, ndation Property Line LEACHING LINE D No. & L of fines I length/size FILTER BED ❑ nce to nearest: Well Foundation rty Line SEEPAGE PIT { I Depth Size Number SUMP LI Distance to nearest: Well Foundation Property Line SPOSAL PONDS ❑ i; I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la and rules and regulations of the San Joaquin County 1 1. 5 L 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 subcontracting signature eartifies 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 ail required inspections.. Complete drawing on reverse side. Signed �� Title: Dale: c R DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout inspection by Date // � F�i/n�al Inspection by Date Additional Comments: /�Q� (� DCj-7/ 7°Cy__ _.,... Applicant - Return all copies to: San Joaquin County Public Health Servicers Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO �yAMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT'NO. . EM�Y24 TREY.1/n51 Q ' J 7(/ e9 a �y EH 5476 l r 6 i/