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APPLICATION 1 1� ll 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 EXPIRES I 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 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. Job Address City Lot Size/Acreage IJ�Aj Ll Owner's Name �'[ ' Add ss n cpm Phone �- Contractor cz�✓ .� _ _—_Address --License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 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 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack7 C7 Tracy Type of Casing_ Specifications I'1 Public M Other I-1 Delta Depth of Grout Seal Type of Grout .- I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 13 Type of Pump H.P. State Work Done T Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Materiel & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR IADDITION ( DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.)Installation will serve: Residence j�Commercial Other Number of living units: __L_ Number of bedrooms Character of soil to a depth of 3 feet: 'll*""t-Q Y � Water table depth L 0 SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of isp I Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines ,. Total length/size FILTER BED or Distance to nearest: well 0 Foundation ( Property Line u, `Z 4f 0 s 4----A,- - - - - SEEPAGE PITS I I Depth Size Number SUMPS 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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 mut all f ai ed ins ctions Complete drawing on reverse side. Signed ae Title: Date: FOR D RARTM USE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P Hox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOU T REMITTED CK I JI JfCEIVED BY ATE INFO PERMIT NO. . EM 13- 4INIrv.F/H51 FFF Y / r