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APPLICATION j SAN 'JOAQUIN COUNTY PUBLIC HEALTH-'SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PH NE (209)468-3420 P 0 BOX 2009, STOC TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 eompliaslce with San Joaquin County Ordinance No. 50 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ^ Job Address Yr � ity/� Lot Size/Acreage Z� Address R0li� Phone 9r Owner's Name .� Contractor A0 t _Addres � _ _ License Not. � -Phone- - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION"F Out'of'service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR Ll OTHER Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !/ Cl Industrial ❑ Open Bottom .0 Manteca Dia. of Wel Excavation pia. of Weil Casing Cl Domestic)Private Ci Gravel Pack ❑ Tracy Type of Casing- Specifications I'1 Public Other F1 Delta Depth of G out Seal Type of Grout r I I Irritation — Approx. Depth I I Eastern Surface Seal Installed by ,ep ' Repair Work Done 0 Type of Pump H.P. __— State Work Done _ Well Destruction ❑ Well Diameter sealing Material Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I D ESTRUCTION I I (No 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 soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Cap city 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 Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be dons 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 tie 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 subcontracting signature certifies the following: "I certify that in the performance of the work tar which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The apple ant must call for all req 'red ins c ionsomplete drawing on re side. Signed S Title: Date: !✓" FOR DEPARTMENT L SE ONLYl•��. S .35, OZ "Y3Application Accepted by C, Date Area Pit or Grout Inspection by Date 'f�'Z j' Final Inspection by _..__— _ _ ______- Data Additional Comments: It_ l n Applicant - Return all copies to: San Joaquin County Public.'Health Services Environmedtal Health Per it/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CKS INFO FEE AMOUNT DUE A�MOUNT REMITTED CASH hRECEIVED BY �1DATE -y PERMIT'N�O. EH13.24{REV-i/AW . t•✓ rl�� ' _ `� �'�J�'` ]tiJ 1 �J % f EH 11.20