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APPLICATION 0, `* r I " SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �� 445NOXJ2009, STOCKTON, O 420 A)95201 P 0 PERMIT EXPIRES i YEAR FROM DATE ISSUED �7 (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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job AddressTO�� _ City ol Lot Size/Acreage Owner's Name all- �. r7.�.:f�.;. ddress _ ��.rs" Phone. -�--�1 t .� ConlraC k� Addre (ff � License es _Phone TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT Cl _ DESTRUCTION ❑ Out of service Well 0 PUMP,INSTALLATIONT� SYSTEM REPAIR Ll OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 'stlE SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Iu 1 ❑ Open Bottom ClManteca Dia:of Well Excavation Dia."of Well Casing omastic/Private Cl Gravel Pack ❑ Tracy Type of Casing__ Specifications i 1.1 Public f-1 Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation -Approx. Depth I I'Eastern 15urfaee Seal Installed by Repair Work Done 0 Type of Pump H.F. ,j State Work Done Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence_ Commercial _ "Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line a LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED i=1 Distance to nearest; Well Foundation property Line I SEEPAGE PITS 11 •Depth Size Number SUMPS LI Distance to nearest: Well Foundation Properry'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 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 II required in Complete drawing on r rse side. _ c,I- Signed X Title: Date_ r �{ter `I R DEPARTMENT USE ONLY Application Accepted by Dater r. 1 Area o 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 O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 13 DATE PERMlT'N0. FEE EH 14-M .ti • Eli 13-Z4 IREV,r i n SI 45 ,.�/} I---- V1,01-1-3z "