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APPLICATION ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES -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 f application is made in eoupliance *with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. E , Job Address �2 � City Lot Size/Acreage Owner's Name Address 12 O Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service We11 ❑ T 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 C1 Industrial ❑ Open Botiom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing }� I (:l Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications Cl Public 1-1 Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approxi Depth I 1 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H,P, State Work Done _ Well Destruction ❑ Wolf Diameter Sealing Material & Depth Depth f Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I "DESTRUCTION (No seplic'system permitted if public sewei is available within 200 feet.) installation will serve: Residence 1 Commerc! f +■ Number of living units: Number of bedroo •" Character of soil to a depth of'3 feet XP ter table depth SEPTIC TANK ❑ Type/Mfg ._ iE IO! IY No. Compartments PKG. TREATMENT PLT.❑ Fri ly Method of Disposal Distance to nearest: 1 00.1 Ar aeetty Line LEACHING LINE Cl No. & Length of lines F YoWr /size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size -4 Number SUMPS l:) Distance to nearest: ' Well Foundation Property tine DISPOSAL PONDS ❑ I hereby certify that I have prepared thii 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 iignatu`re cenifies the following; "I certify that in the performance of,the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation taws 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 f r II p squired i�,ctions. Complete drawing an reverse side. t Y - !\ Signed Title:�lal,I Pk-s Date: .�,�" EPRTMENT USE ONLY App etion Accepted by 1 e�� ld,� Date Z ^ Area Pit or Grout Inspection b f Date Final Inspection by Date Additional Comments: L&-2 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 IFCC AMOUNT AVE AMOUNT REMITTED C 5H RECEIVED BY DATE PERMIT'NO. k . EH 13-241REV.$ 51 /w` EN 14.25 � {/ � 1_.-.y 4