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SAN UIN COUNT? PUBLIC HEALTH &,.OICES L� t lENVIRONMENTAL HEALTH DI V I S IOW 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 (Complete in Triplicate) Applifatiett is her*by stadf,to Baa Joaquin County for a permit to construct and/or install the work herein described. This twlleatiea to ■act la eottpIlene* with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address _. 1 1�[! f CZ�. � L � City _ Lot 81 xe/Acreage Owner's Nadi* _ AddressAA�� — Phone • Mo 6,10 Contractor Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Veil PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L. &7; ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE }10 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f.7 Industrial O Open Bottom ❑ Manteca pie. of W*N Excavation Dia. of Well Casing tG n (I Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing___ Specifications Fl Public F1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by V' Repair Work Dont U Type of Pump H.P. rLtale Work no f f.d Wall Destruction ❑ Well Diameter Sealing Material i Depth Depth biller Material i Depth s1M. TYPE OF SEPTIC WORK: NEW iNSTALtATfON 1 I REPAIRIADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet) Installation vA serve: Residence_ Commercial_ Other Number of wing units: Number of bedrooms Cheracter of soli to a depth of 3 feat: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Ll Method of Disposal Distance to nearest: Well Foundation Property Lin* LEACHING LINE CI No. & Length of lines Total length/size FILTER SED C1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: WON Foundation Property Line DISPOSAL PONDS ❑ t hereby certify that I haw prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end rules and roguish"of the San Joaquin County Home owner or licensed apent's signature certifies the following: "I certify that In the performance of the work for which this permit is issued, I shall not Wnplay a"person In such meaner as to belcom subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature ce WW9 the fallowing: 'I certify 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 Carfornfe." The -ppilretv t cart)a p*ed inspection$. Complete drawing on reverse side. 7 [} Signed Title Date: R DEPARTMENT USE ONLY Application Accepted by Data � � f1r*a Pk or Grout Inspection by Date Final Inspectio by Data �Z Additional Comments: Applicant - Return all copies to: Ban AoRquinCounty Public Health Services Environmental Health Permit/Services 448 N San Joaquin, P O Sax 2009, Stkn, CA 95201 1FEE AMOUNT DUE AMOUNT REMITtEQ CASH RECEIVED SY DATE PERMIT"NO. . ir,t3.38 tai, E,�, � 3-� z EN r1•ia . � � D-0 V ��