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APPLICATION -- —� } SAN JOAQUIN COUNTY PUBLIC HEALTH SERV CES ENVIRONMENTAL HEALTH DIVISION AID ## 4 ` �i 445 N SAN JOAQUIN,PHONE(209)469-342Cn P O BOX 388,STOCKTON,CA 95201-0388 FAC PERMIT MIRES x YEAR FROM DATE (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 Development Title Section 9-1110.3 and Section 9-1115.3 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ` City Lot Size/Acreage Owner's Name _ Address J , Contractor f f Address ✓°f license N0.42_-7_Phan TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 171 DESTRUCTION ❑ out of Service Weii 0 PUMP INSTALLATION 1� SYSTEM JPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ZVJd? SEWER LINES DISPOSAL FLD. PROP. LINE LLL l FOUNDATION f AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it Cl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing W<Domestic/Private 00ravel Pack ❑ Tracy Type of Casing_ Specifications t'I Public A I1-1 O�th,A, n Delta Depth of Grout Seat Q Typo df Gfou RZ 5.7 I I Irrigation a-e Kp o■. Depth I I Eastern Surface Soul Installed by Repair Work Done' U Type of Pump H.P. State Work Done_ Well Destruction © 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 INo septic system pemitted it public sewer ist available within 200 feet.! Installation will serve: Residence—. Commercial— Other ° Number of living units: Number of bedrooms PAYMENT Character of sod to a depth of 3 feet: Wa1jJ FED SEPTIC TANK ❑ Type/Mfg Capacity No. Comets{{ PKG. TREATMENT PLT.❑ Moth"X11111 s Distance to nearest: Well _ Foundation Propert annfi C UNT _ � tt4 pt-TH SEMCES LEACHING LINE El, No. & Length of lines Totai lenge TALMLALIM FILTER BED: n Distance to nearest: Well Foundation Property Line l/ SEEPAGE PITS 11 Depth Sire Number IIF SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 certity that in the performance of the work for which this parrtut 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, 1 shall employ persona subject to workman's compensa- tion laws of California." The applicant Jrpust call for all required insPections. Complete drawing on reverse side. Signed �La4 C Title: N—I M, .._ Data: dr l� FOR DEPARTMENT USE ONLY A a n Accepted by Date Pit Grout napection by. Data Final Inspection b Date ,G/ , AdddlonaI Comments: Applicant - Return all copies to: San Joaquin County Public Health Services f, Environmental Health PermiUServices 1{ 445 N.San Joaquin,P.O.Box 388,Stockton,CA 95201-0388 e FEE AMOUNT CK DUE AMOUNT RECEIVED 6Y DATE PERMt7'N0. � r INFO H EH t3.24 111E�r.i i e Sr . 0 V .�'"' J✓ [/Yui V�4�~ 1 � EH 4'.20