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APPLICATION SANPOAQUIN COUNTY PUBLIC HEAL ACES ENVIRONMENTAL HEALTH DIVI (0 1A A A I^ 445 N SAN JOAQUIN, PHONE (209 q fit\ P O BOX 2009, STOCKTON, CA J5A�`# PERMIT EXPIRES 1 YEAR FROM DA ED (Complete in Triplicat ) Ny Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein des crl ed. s application in made in compliance with San Joaquin County Ordinance No. 5L9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /� /� Job Address r`_1 City .AfL-�A/__ Lot Size/Acreage Owner's Name (�-�M � 1/ /S► Address ��Crf Phone Contractor. LJ' ,_� i+ ss __ _J _ ,� _' Phone TYPE OF WELL/PUMP: NEW WELL WELL %ACEMFNT (l DESTRUCTION (_ Out of Service Well 0 PUMP INSTALLATION O SM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK �~ SEWER LINES -^ DISPOSAL FLD. PROP. LINE_ FOUNDATION -- AGRICULTURE WELL OTHER WELL Zlfi?ZT__ PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS We $ ./ h lndustnal C) Open Bottom ❑ Manteca Dia. of Well Excav tion � _ Dia. of Well Casi I Domestic/Private ( -Gravel Pack O Tracy Type of Casing_ _ Specificationsb/ ('i Public (I Other ( )FsDepth of Grout Seal Type of Grout!. s� I Irrigation �(„L Approx. Depth tern Surface Seal Installed by Repair Work Done LJ 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 I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/ i e FILTER BED CI Distance to nearest: Well _ Foundation Props r SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS U 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 f1 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 1 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 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 applic m t c o all requir i spec ' . Complete drawing on to a side. Signed Xi/ Title: d Date: FOR DEPARTMENT USE ONLY 1 Application Accepted by _ Date Area "` /09 Pit or Grout Inspection by Dat Final Inspection by Date o Additional Comments: "— Applicant - Return all copies to: San ,Joaquin County ublic Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. FH 1324 IREV. f r �\ I✓�/ G j� 9 /[1 ? �/�f EH 14 26