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- APPLICATION. ' x SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION j 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 A' t PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cample,te 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 , i Joaquin County Y,ublic Health'¢ery - do. 01 €I City #x/ , Lot Size/Acreage Job Address ''� `� Address Z Owner's Name tr�.SAddress. lt'�r�l�C License No. ;Z!ZV 3 _Phon Contractor e TYPE OF WELL/PUMP: V NEW WELL ❑ WELL REPLACEMENT DESTRUCTION X out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C1 i DISTANCE TO NEAREST: SEPTIC TANSEWER LINES DISPOSAL FLO. ZdP PROP. LINE K E)I 11_ -. FOUNDATION AGRICULTURE-WELL OTHER WELL"'"."„2C5--"- PITS/5l1MPS"`-.I--' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ��`r Dia. of Well Casing Domestic/Private Gravel Pack n Tracy Type of Casing- Specifications ..y��Z/,20 - �! J2 I'4 Public la Other Cl Delta Depth of Grout Seal Type of Grout i + I i Irrigation Approx. Depth l I Eastern Surface Seal Installed b Repair Work Done ❑ Type of Pump H.P. State Work Done I Well Destruction Well Diameters� waling Materiel 6 Depth 9 k Depth r�l� _- Filler Material & Depth E� TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION I I INo septic system permitted ' public sewer is t available within 200 feet.l 4 Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms It Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT,PLT.0:.i, Moth° Disposal Distance to nearest: Well Foundation Property Linb RECrp LEACHING LINE ❑ No. B Length of.lines Total length/sizeA 1 0r FILTER BED ❑ Distance to nearest: Well Foundation Prop , ine 2 f V IVV (,.c)j SEEPAGE PITS II . Depth Size Numb&11 J'QQAtn 4 ' ` AL 'r:, r, yri J SUMPS _ LI Distance to nearest: Well_-Foundation Property-line-� -_°Li�i 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 EI I rules and regulations of the San Joaquin County I 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, l shall not: employ any person.in such manner as to become subject to workmen's compensation taws 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, 1 shall employ persons subject to workman's eompensa I I tion laws of Calif mia." i The applicant st call for all requirespections. Complete'drawing o reverse dWIJA Act I Signed X Title: Date: '12A� FOR DEPART ENT E ONLY EE j Application Accepted by Date Area Pit or Grout Inspection by Date__-_�- Final Inspection by Date�� • Additional Comments: TS F` ).skJ-,D )O* ' (15, 1 67e&47 30 A,, A Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services �C[s 445 N San Joaquin, P O Box 2049, Stkn, 4A 95201 �t!1�� -S (91dWO 45--30 � 'so {o�- INFE AMOUNT DUE MOUNT REM1TTEi] CASH' RECEIVED BY DATE PERMIT'NQ. i• a _