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APPLICATION ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONNLENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PRONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA. 9520I PERMIT EXPIRES 1., YEAR FROM DATE ISSUED (Complete in Triplicate) Application in hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coupliance with San Joaquin County Ordinance No. 549 and 1869 and the Rules and Regulations of San Joaquin County Public health Services. Job Address City_ Lot Size/Acreage Owner's Name Address Phone Conlraclor Address _ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION Out of Service well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ 14ohitoking Well D DISTANCE TO NEAREST: SEP71C TANK SEWER LINES DISPOSAL FLD. PROP. LINT FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1.1 Industrial 0 Open Bottom 0 Manteca Ois. of Well Excavation Dia, of{M1leh Caaing ` j 11 Domestic/Private ❑ Gravel Pack n Tracy Type of Casing_ Specifications I'1 Ptibtic 1-1 Other 1-1 Delta Depth of Grout Seai Type of Grout 111rrigalion — Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _ State Work Done �- Well Destruction ❑ Wel! Diameter Sealing Materiel i Depth Depth ,Filler Niteriel i Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public surfer 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 i I SEPTIC TANK 0 Type/Mfp Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED n Distance t0 nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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, slate laws, and rules and regulations of the San Joaquin County Home owner or lieensad agent's signature certifies the following': "I certify that ih the performance of the work for which this permit is issued, I shall not employ any person in such manner it,to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature canifies the following: "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 California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: Data: FOR DEPARTMENT USE ONLY Application Accepted by Date 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 Pormit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 85201 FEEINFO AMOUNT DUE AMOUNT REMITTED C SH �bRECEIVED CK 9 BY PATE PERMIT'NO. EH }s ISEv.�r n 51 FN 14-M 4