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APDT,TCAT ION ;Jft SANJOAQUIN COUNTY PUBLIC HEALTH SENVIRONMENTAL HEALTH DIVISIO445 N SAN JOAQUIN, PHONE (209)468P 0 BOX 2009, STOCKTON, CA 952PERMIT EXPIRES 1 YEAR FROM DATE I (Complete in Triplicate) 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. p� Job Address0 ' 1 r Cry /� Lot Size/Acreage Owner's Name Address P,/ / S� , Phone Contractor E ddress License No. Phone TYPE OF WELL/P MP. NEW ELL ❑ WELL REPLACEMENT C DESTRUCTION G Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR E OTHER G Monitoring Well ky DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE S� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C, Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'i Public F] Other 17 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADOITJON ! DESTRUCTION I I INo 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 coil 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 LEACHING LINE ❑ No. & Length of lines Total length/size_ FILTER BED ❑ Distance to nearest: Well Founaation Property Line 1 SEEPAGE PITS I I Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line 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, 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 rtify 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.' t t� The applicant mustor all required i spectio . Complete drawing on rse side. v` Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by // D /ate ` � Area �Cf Pit or Grout Inspection by Data Iib Final Inspection by Additional Comments: 4 Applicant - Return all copies to: IJ San Joaquin County Public Health Services D Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK ICASH RECEIVED BY DATE PERMIT NO. • EH 1m3-24 ERIN. liner EH ,..