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� I APPLICATION J SAN JOAQUIN COUNTY PUBLIC HEALT $> jV�jC ENVIRONMENTAL HEALTH DIVI X 445 N SAN JOAQUIN, PHONE (209 � 20 P O BOX 2009, STOCKTON, CA PERM1T EXPIRES 1 YEAR FROM D (Complete in Triplicat Application is hereby made to San Joaquin County for a permit to construct an ■ts scribed. This application 1s made in compliance vith Son Joaquin County Ordinance No. 5L9 and 18 an ns Joaquin County Public Health Services. Job Address � - C iyLot Size/ACrerge Owner's Name'' Address ! �� — _ ____�.._ _ Phone Contrac � _�� dresllP X30 License Nr ..�,�.' - �3� Phone ^ TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ll out of Service dell D PUMP INSTALLATION L+ � SYSTEM REPAIR L4+ OTHER O Monitoring Well U 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 F Ind el ❑ Open Bottom D Manteca Dia. of Well Excavation_ Dia. of Well Casing C Oomasuc/Private Cl Gravel Pack E7 Tracy Type of Casing_ Specifications I'l Public (-I Other (� Delta Depth of Grout Sea! Type of Grout + I Irnpatron �_ Approx. Depth 1 1 Eastern '9uriaea Seal Installed by Repair Work Done 6d Type of Pump H.P. _j i1�� ____ State Work Done Well Destruction 0 Well Diameter Sealing Material i Depth Depth Filler Material k Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ' i REPAIR/ADDIT!nN i ! DESTRUCTION I I [No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Otli Number of iivog unitsr Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capa'ity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line i LEACHING LINE L1 No. A Length of lines _ _ Total length/size FILTER BED C) Distance to nearest: Well Founcatron _ Property Line SEEPAGE PITS 11 Depth _ Size Number_ SUMPS LI Distance to newest: Well , Foundation Property Lina DISPOSAL PONDS ❑ 1 hereby certify that I have prepared thin, application and that the work will be done in accordance with San Jnaquin county ordinances, stare 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 sublect 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'■eompenss- lion laws of California." The applicant mu 1 ell required ins coons. Complete drawing on�verse s+de. Signed X �_ _ y Title: Date: 3 FOR DEPARTMENT USE ONLY Q Application Accepted by gA Aka, e _ Date - e Area_ Pit or Grout Inspection by a Date Final Inspection by ~ Data Additional Comments: Applicant Return n11 copies to: Sen Joaquin County Public Health Services \/[ a/)��✓`' • / , QQ�1� Environmental Health Permit/Services Jul V rD 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 ��v FEE INFO AMOUNT DUE AMOUNT REMttTEO C'/A/7SH RECEIVED BY DATTEE PERMITNO. EH 13.24(Rev 1,45) V. ' �• `-'�� n/ ��.' OZee! !3' l EH 11-2a