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APPLICATION U JSJ=QUIN, COUNTY PUBLIC HEALTH S SR # NTAL HEALTH DIVISION COPY u !44-5 N PHONE (209)468- 4 AID # 2009, STOCKTON, CA 95201 FAC # PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AS �nI11�� }} ( mplete in Triplicate) i& bttf3 for a permit to construct and/or install the work herein described. This an oagixln County Ordinance No. 544 and 186�i AL�e_.Rules and Regulations of San Joaquin County Public Health Services. : 44 Job Address 0 CityiEt Size/Acreage TNw Owner's Name ¢ Address Sam - - ---— -- Phone ��✓ Contractor Address _T/ .ir .� � License No. Phone l TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service We11 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER-9— 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public 1.1 Other Cl Delta Depth of Grout Seal Type of Grout t I Ifrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth C TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 2W feet.) . Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soli to a depth of'3 feet: Water table depth SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Dista ce to nearest: Well Foundation Property Line SL ACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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."Contractors hiring or sub-contracting signature certifies the following:"I ce ' that in the perto ce of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of Californ The applicant gnus o If it Y ns. Complete drawing on reverse ide. (�- Signed � Titlt�`!/C{'�+�1 aG'I IZ2 _f_1 ------ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by��JJ&S2 //�� pp AA Data Final Inspection by Date Additional Comments: 1!]is/jy�1jN_� Applicant Return all copies td: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT.REMITTED K RECEIVED BY OAT PERMIT NO. Eli-xscrttv...rRsi I/JCY* l�J '� = o`�o�f� r ��