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APPLICATION - 1, 01 ' SAN JOAQUIN COUNTY PUBLIC HEALTH S VI ENV I RONYENTAL HEALTH D I V I S 4 QD # _ fit/ 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009 , STOCKTON, CA 452b�'. ff PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicated l Application Is hereby made to Sam Joaquin County for a permit to construct and/or install the work herein described. This application is amde in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and R!gulations of San Joaquin County �Putlic�Health Services. Job Address —Ag—1 � r _ Ciry Lot Size/Acrerge _ Owner's Name Address J C, '�_ ��' _ Phone 2-L12 Contractor ` Address PQolf License No. Phone –L� TYPE OF WELLtUMPjk NEW WELL O WELL REPLACEMENT F1 DESTRUCTION Cl Out of Service Well D PUMP INSTALLATION O SYSTEM REPAIR A OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES —T DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (I Industrial C) Open Bottom i(Manteca Dia. of Well Excavation Ois. of Well Casing $DomesticlPrivaie ❑ Gravel PacIk7 Ll Tracy Type of Casing__ Specifications I'1 Public 1-1 Other (I Delta Depth of Grout Sea! Type of Grout I I Irri0atron __Approx. Depth /I I Eastern Surface Seal Inswiled by Repair Work Done Type of Pump 4."& H.P. — __ State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Piller Material A Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I REPAIR/ADDI i IOM I I DESTRUCTION I I lNo septic system permitted it public sewer is 1J� available within 200 leet.) « 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, D Method of Disposal CTT` Distance to nearest. Well Foundation Property Line T LEACHING LINE ❑ No_ & Length of lines w Total length/size ` FILTER HED ❑ Distance to nearest: Well Founoatron — Property Line SEEPAGE PITS 11 Depth Sue _ _ Number_ SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl I hereby cenity, that I have prepared Chir, application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end _ rules and regulations of the San Josouin County Home owner or licensed sgant's signature certifies the following: "I certify that in the performance of the work foe which this permit is issued, I shall not f employ any person in such mann,as to Become subject to workman's compensation laws of California." COntracto;'s hiring or subcontracting signature f]d_ certifies the foNowing: "I Certify that in the performance of the work for which this permit is issued. I shall employ persons subject to workman's compansa- tan laws of California." The applicant It_st call for auired inspections. Complete drawing on reverse side. Signed XTitle: � +� Date: I. FOR DEPARTMENT USE ONLY Application Accepted by _ _ Date Aroa_ Pit or Grout inspection by Data Final Inspection b Date Addition&! Com~ls: Appllcat,t - Return all copies to: San Joaquin County Public Health Services ��1\Vy Environmental Health Permit/Services i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 F1iIEO l` rfAMOUNT DUE AMOUNT REMITTED C SN RECEIVED BY DATED PERMIT-NO. • EM 13-24 III EV.I i n I 5) P` I �� EH 1{.2a T