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APPLICATION SAN"JAQUIN COUNTY PUBLIC HEALTH ENVIRONMENTAL HEALTH DIVIS 445 N SAN JOAQUIN, PHONE (209)46 - 420 ' P 0 BOX 2009, STOCKTON, CA 9590 2 1993 PERMIT, EXP I RES I YEAR FROM DAM\kRAW (Complete in Triplicate) PERMIT/SE VCES� i� Applicationis hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in liccuplience vith San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Joh Address �l ►v� _ City � l.Ot Size/Acreage II Owner's NameN�ZP Address S � � Phone Contractortt �� _Address License No 1 0 i Phone TYPE OF WELL/PUMP; I MEW WELL ❑ WELL REPLACEMENT n DESTRUCTION o Out of Service Well ❑ PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER.2��p�nitoring ell ❑ DISTANCE TO NEAREST: SEPTIC TANK -4 ANK SEWER LINES 2� DISPOSAL FLD.� PROP. LINE FOUNDATION �O i AGRICULTURE WELL OTHER WELL N/Q" PITS/SUMPS 600- INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 In ustrial O Open Bottom ❑ Manteca Dia. of Well Excavation �� Dia. of Well Casing Domestic/Private Cl Gravel Pack n Tracy Type of Casing_ " Specifications ^' 1'1 Public G1 Other n Delta Depth of Grout Seal �5� Type of GroutA*024VVd I I Irrigation 11 Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done U type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter`% '� Sealing Material & Depth ' Elepth _ ' Filler Material & Depth { TYPE OF SEPTIC WORK: )NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is !M. I available within 200 feet.) 1 1111 Installation will serve: Residence_ Commercial._ Other i Number of living units: 4 Number of bedrooms Character of soll to a depth of 3 feet: Water table depth 1I+I SEPTIC TANK ❑i Type/Mfg Capacity No. Compartments C I PKG. TREATMENT PLT. 61 Method of Disposal Distance to nearest: Well Foundation Property Line 1 e LEACHING LINE Cl' No. & Length of lines Total length/size tet' FILTER BED ❑� Distance to nearest: Weil Founaation Property Line i SEEPAGE PITS 1 I; Depth Sue Number C �I SUMPS LIQ Distance to nearest: Well Foundation Property Line [. DISPOSAL PONDS ❑ i 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, and rules and regulations of 1he-ISan Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which.lhis 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 hir ng of sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, f shall employ persons subject to workman's compensa- tion laws of California." The applican st II squired i drawing an averse side. t Signed X I� Title: Date: FOR DEP TMENT USEANLY Application Accepted by ¢ i' � Date 1 Area L `11�)� Pit or Grout Inspection by I' Date Final Inspection by e l l `� i a Additional Comments: L1 i Applicant - Return all copies to: San Joaquin County Public Health Services I� Bevironmental Health Permit/Services �D 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 1 �i GEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. INFO EH H ]-24(REV. 5� 12 /�t4-M R