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APPLICATION FOR PERMIT n SAN j70AQUIN COUNTY PUBLIC HEALTH :;IiRVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i � . P EXPIRES 1, YEAR FROM DAZE ISS (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 Ordl c o. 5and 1862 the Rules and.'Regulations of San Joaquin Count Public HealthServices. r) � � �/V. l ] 1�`� V Yl City Lot Size/Acreage Jeb Address 2 r� 's Name re Phone�� r 5k�i� ss 71Z6 fl )V nee No. n hone Y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP iNSTALLATkON`� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ k DISTANCE TO NEAREST: SEPTIC TANK jjj SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q ustrial. ❑ Open Bottom ❑ Manteca Dis. of Well Excavation Dia. of Well Casing stie/Private ❑ Gravel Pack r 'E] Tracy Type of Casing Specifications Al Public (l Delta Depth of Grout Seal Type of Grou I I Irrigation = —.Approx. Dap t 1 Ea n Surface Seal Installed by Repair Work Done 0' Type of Pump H.P. State Work Done 49 yl LULU Well Destruction ❑ Well D' t f Sealing Material i Depth E�pth Filler Material i Depth fill TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION'I I DESTRUCTION i I INo septic system parmitled if public sewer is available within 200 feet.) Instakation will serve: Residence_ Commercial_ Other +� Number of living units: Number of bedrooms w Character of will to a depth:.of 3 feet: Water table depth SEPTIC TANK. ❑ :Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Q _ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. b Length of lines Total length/size FILTER BED ❑ - Distance to nearest: Well Foundation Property Line r SEEPAGE PITS '41 Depth Size Number SUMPS y,L.l" Distance to nearest: Well Foundation _ property Line DISPOSAL PONDS 0 I hereby certify that.1 he"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 shell not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sulci-contracting signstuie certifies the foAowing: " "Mr that in the paAgrmanca of the work for which this permit is issued,1 shall employ persons object to'workman's eampsnsa r tion laws o fomia.' 11 Thea at can an u sd in tions. Complete drawing on verse s' a.. . � Sig Title � Date: k , FOR DEPARTMENT USE ONLY ( r Application ("'I't Accepted by -'^"^ Date `r✓' /,ZtAr Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services I _ _Environmental Health Permit/Services 445 N San Joaquin; P ax 09, Stkn, CA 95201 ilk NFEAMOUNT DUE AMOUNT REMITTED GASH EIVEO BY 0 TE PERM17'NO. • EH 13-24{REV.1/R EH 14.26