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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 2ERMIT EXPIRES.]. YEAR FROM DATE I UID (Complete in 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health )Services. p ."Job Address �f /�L r�_�gy7 + �/ _ City Lot Size/Acreage v Owner's Name S Address Pbone V 164F, (/ Contractor __ Address_ License No. Phone j TYPE OF WELL/PUIv1P; NEW WELL ❑ WELL REPLACEMENT rl DESTRUCTIONV Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well L7 i 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 In Industriai 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 'r 01 C1 Ll Gravel Pack [7 Tracy Type of Casing_ Specifications C1 Public F1 Other F1 Delta Depth of Grout Seal Type of Grout { i I I Irrigation _ .Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type'of Pump ' ' "" _ H.P: State Work Done _ Well Destruction ❑ Wel! Diameter _ t4 Sealing Material i Depth x (y__ Depth-.--. Filler Material Ii Depth ' TYPE OF SEPTIC WORK; NEW INSTALLATION 1 1 REPAIFI/AODITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet,! installation will serve: 'Residence — Corprpercial.—, Other Number of living units: .,,,.,,— Number of l4drooms Character of soil to a depth of 3 feet: _ ' g x ' _ _ ,,,,,...,,.. ...,,..,....,�--Water table depth SEPTIC TANK ❑ Type/Mfg 'Capacity No. Compartments PKG, TREATMENT PET.❑ —Method of Disposal----- Distance to nearest: Well �'r �`r Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size f FILTER BED to Olstance to nearest: Well Foundation Property Line SEEPAGE PITS:. 1'1-'\Depth 1 Size Number SUMPS t LI Distance to nearest: Well Foundation, Property Line ; 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 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 pars ch manner as to become subject to workmen's compensation laws of California," Contractor's hiring or subcontracting signature cartifies the fotlowr : "'I ca that in the rmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califom r The applies st cal f all ctions, Complete drawing on#revve side. L-1Signed X Title; -,Y� _ _ ,. Date: Z-611 i r OR DEPARTMENT USE ONLY Application Accepted by Date -� I,JArea Pit or Grout inspection by Date _ Final Inspection by Date a Additional Comments: ` It- Applicant - Return all copies to: San Joaquin County Public 'Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Sox 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED,Q ICASH KAT RECEIVED BY DATE PERMIT'N0 a EM f3-24{rtEV.r n 5s W. EH i42e l/ vG6. O O /+&! I/— oc;)9� Q y y