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APPLICATION FOR fDI SAN JOAQUIN COUNTY PUBLIC BNVIR�TAL HEALTH445 N SAN JOAQUIN, PHONEP O BO% 2009, STOCKTONPERMIT EXPIRES 1 FR (Complete in Triplic MV 3 Application In hereby made to San Joaquin County for a permit to construct and/or inattal.l the vort s application is made in cowliance vitt San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job r �r Job Address , � %,a v" x� ', Cityli Lot Sixe/Acreage Owner's Nana 1 Address �U' Contlacte� 11i1� ��(i� l�Y Address PP b—C TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Veil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Vell ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dis- of Well Excavation Dia. of We! Casing n Domestic/Privsts ❑ Gravel Pad1 ❑ Tracy Type of Casing Specifications VI Public n Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. States Work Done— WON Destruction ❑ well Diameter Sealing Material i Depth Depth Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I 'kEeA"DoiTio0< DESTRUCTION I I INC septic system permitted it public sewer a available within 200 feet-1 Installation will serve: Residence Commercial_ Other Number of wing writs: Number of Corns Character of sod to a depth of 3 fast: r �-` �Y Y`�'s'� Water table dap ,_ SEPTIC TANK. ❑ Type/Mfg +L CapacityNo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Lina_. e LEACHING UNE No. >i Length of tines 10 0 Total length size K FILTER BED 0 Distance to nearest: Wolf r .Foundation_#f1 Property Lina _S �7 SEEPAGE PITS I 1 Depth Sire Number [�> SUMPS LI Distance to rawest: Wall Foundation Property Law DISPOSAL PONDS ❑ I hereby candy that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, 31810 laws, and ruins and regulations of the San Joaquin County Home owner or licensed agent's ipnature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any perms in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature cortifisa the following:"I candy that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laves of California." The applicant call for, required inspections. Complete drawing on reverse Signed _ :k ,�r Title:_ -• - --_ Date: '�r11 C1 Ll s FOR DEPARTMENT USE ONLY Q Application Accepted by v� Date f '� ` Area r Pit or Grout Inspection byData Final Inspection by Addkional Comments: - Applicant - Return all copies to: Sas Joaquin County Public Health Services Rsvironmental Health Permit/Services 445 N San Joaqu x 2009, 3tka, CA 95201 cAttFNFO AMOUNT DUE AMOUNT 11EMITTED t K H AECENED 0Y DATE PERMIT-NO.