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APPLICATION `S SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION No W a 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 No C PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 1862 and the Rules and Regulations of San Joaquin County Public Health Services.. �Qte I.tip.y�ap� Nb Address _ � � - City Sf� - Lot Size/Acreage Owner's Name�� ` Address L L"-,c J06 Phone kontraclof(5 Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 Out of Service Well. ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL, OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f"l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications N 1'1 Public 1-1 Other ' Cl Delta Depth of Grout Seal Type of Grout I I Irrigation Approxi 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 Materiel i Depth Depth Filler Material & Depth } E TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTIONPN INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial Other i 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 y ! PKG. TREATMENT PLT. ❑ �: Method of Disposal �-Distance to nearest: Well Foundation - Property Line LEACHING LINE 0 No. &Z. rigt6j of lines Total length/size FILTER BED C] Distance.to serest: Well Foundation Property Line SEEPAGE PITS It Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation~_''^ Property Line DISPOSAL PONDS ❑ ( 1 I hereby certify that I have preparedk totstwpplicatioP-'and that•the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaq`ul _C'ounsy Q f '� Home owner or licensed agent's signature certifie�the following'"I certify that in the perf OTmance of the work for which this permit is issued, I shall not employ any person in such manner a is becomeAubjeccttto 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 per,mit.is(issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica must II for all required ins ions. Complete drawing on reverse side. ignod X4 AA Tide: \ - � FO f3EPAfiTMENTUSE ONLY - Application Accepted by Data o �- -� Area 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 BY DATE PERMIT NO. : EH13-241REV.t�nsi EH 14.26