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APPLICATION SAN JOAQUIN COUNTY. PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN$ PHONE (209)468--3420 P O BOX 200.9, STOCKTON, CA. 95201 ,y i „ PERMIT EXPIRES1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s hereby made,to San Joaquin County fora permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No.. 549 and 1862 and the,Rules and Regulations ot'San Joaquin county Public Health Services. 0. d� f11/ �r/oZ`3 0� t•0 Lot Size/Acreage Job Address �� n 40 �`�7 Y( >C u Owner's Name Address Phon�.�j9 Contractor ddress _ //l ✓ � 75�{.E�nse No (� TYPE OF WELL/PUMP: NEW WELL ❑ I+ WELL REPLACEMENT f"i DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ a SYSTEM REPAIR C1 OTHER ❑ Monitor1 1We11. -A DISTANCE TO NEAREST: SEPTIC TANK ?�,� SEWER LINES /,./ '719 -- DISPOSAL FLD..,�A��I& PROP:-LINEN� _ FOUNDATION AGRICULTURE WELL .14- OTHER WELL`_ PITSISUMPS _Ll�l INTENDED USE TYPE OF WELL PA08LEM AREA" CONSTRUCTION SPECIFICATIONS aY n ,j Dia, of Well Excavation - Dia. of Well Casing Open Bottom © Ma rata , [l Industrial ■ •'a ul , [l Domestic/Private ❑ Gravel Pack ❑ Tracy Pi Type of Casing �� Z6CSpecifications I'I Public f2:] Other fl Delta t Depth of Grout Seal �� r Type of Grout IL/O 0 Vr JV t 1 Initiation -5,zApprox. Depth I I Eastern 11r Surface Seal Installed b Repair Work Done L7 Type of Pump „ H.P. State Work Done _ Well Destruction ❑ Well Diameter s 9ea11itg [rEaterieil i Depth / Depth r ff Filler material i Depth P �l� TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRJADDITION I 1 DESTRUCTION I 'I (No septic system permitted it public sewer is' + available within 200 lest.l Installation will serve: Residence __ Commercial_ Other Number of living units: Number of bedrooms o Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity "4 No. Compartments PKG. TREATMENT PLY.❑ k Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. b Length of lines Total.length/size FILTER BED ❑ Distance to nearest: s Well Foundation Property Line 1 F 9 'F SEEPAGE PITS 11 Depth Sirs ,' Number SUMPS U Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ~ ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ant rules and regulations of the San Joaquin County 0i . 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 no` employ any person in such manner as to become subject to workmen's compensation laws of California."'Contractor's hiring or sub-contracting signature ` certifies the following: "I certify that in the performanca of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." � The applicant must al! tar alt re uirgd inspactf n . Complete drawing on4rever side. Signed X Title: Date: a r ! ��I DEPARTMENTLIJ ON y z i App cF atlon Accepted by v (G�Lat.� ! O e � Area F r: Pit or Grout Inspection by Date. Finer Inspection by Date Additional Comments: k Applicant - Return all copies to: San Joaquin:,County Public Health Services., Q! ' ld Environmental Health Permit/Services . 1 a rt r4r45 H San,Joaquin, P O Box 2009, Stk , CA'95201 l� r INFO AMOUNT DDiUUEp AMOUNT REMITTED CASH RECEEIIV)ED 8Y DATE PERMIT'NO.