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APPL I CATIONR i � v` :2 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVt(,n ! ^� ENVIRONMENTAL HEALTH DII 445 N SAN JOAQU IN, PHONE (20 P 0 BOX 2009, STOCKTON, C PERMIT EXPIRES 1 YEAR FROM D UID II \ Y -5 (Complete in Triplica 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. ' r 0h'i e C rY`S n Lot Size/Acreage Job Address Owner's Name ^�4r "tet / Address '? !� � � Phone Contractor ! rl (Ir Address l d Ab48kjL_g j4h?j!L License No.111;6XG I?Z Phon�22"� / TYPE OF WELLIPUMP NEW WEL WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C/ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _L lsG— SEWER LINES -- DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL" ! PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Zr i.] Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing (1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingA . 'Specifications i'1 Public Ia Other (I Delta Depth of Grout Seal , Typerof Grout I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H.P. —_— State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth �1 Depth Filler Material i Depth 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 200 feet.) 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line �J LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby cenify 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." Contractor's hiring or sub-contracting signature certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant ust call for all required inspections. Complete drawing on everse r e. Signed X 1� l C Y V l Title: h L DN Date: FOR DEPARTMENT USE ONLY Application Accepted by DateZArea I ' Pit or,Grout pection by Date ) Final Inspection by Data Additional Comments: i Applicant - Return all copies o: San Joaquin County Public Health Services Environmental onPermit/Services t ) /.I��W 445NSanJoaquin, P OBox2009,riStkn, CA 95201 °u� rl7/�y FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PEAMIT'NO. • EN1}2a IREV.rih Sr 0 D EH Ia•2a