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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL REALTI1 DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 ERMIT 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 canpliance with P&a Joaquin County Ordinance No. 51t9 and 662 and the Rules and Regulations of San Joaquin County Public Healt Bervict r Job Address i � City Lot Size/Acreage Owner's Name Addruss . _ _ Phone%0 9 ?S- 1 Conlracta �� 'riddressfi� �[ _License•Nc. `Phone :f TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT _I DESTPUCTION O Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER C Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ISPOSAL `^LD. PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONST TION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Di f Wilt E,cavation. Dia. of Well Casing f I Domesuc/Private Ll Gravel Pack C Tracy ype ofasing Specifications I'1 Public ;a Other (l Dei,a Depth o Grout Seal Type of Grout I'I irrigation — Approx. Depth i I Eastern Surface Seal Installed by 1 Repair Work Done U Type of Pump H.P. State Work Done , Well Destruction C Well Diameter Sealing Material i Depth Depth _ Fill,�r Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION IW REPAIR:ADDiTiON DESTRUCTION t I INo septic system permitted it public sewer is I i / available within 20O feet.l ('�71 Installation will serve: Residence✓ Commercial ter Number of living units; Number of of bedroomsL� Character of BOW to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mf �C Type/Mfg Capacit _ Na, Compartments PKG. TREATMENT PLT. U Method o1 Di I Distance to nearest: Well �oundeGon y7 Property Line ILI LEACHING LINE ❑ No. 6 Length of lines l elf j T91al length/size.- FILTER BED O Distance to nearest: Well Fet naation Property Line SEEPAGE PITS 11 DepthSize, N�'Jmbar SUMPS LI Distance to nearest: WellVjndation �_ Prcperty Line DISPOSAL PONpS ❑ 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 ruNs and regulations of the San.ioaQutn county Horth owner or licensed agent's signature certifies the following. "I certify that in the performance of the work fur 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 certify that in the performance of the work for which this permit is issued, I shall employ pgrsons subtect to workmen's compensa- tion laws of California." The applicant at ull for tied ins actions. Complete drawing on reverse side. Signed , Title: Q �L Date: / ''� FOR DEPARTMENT USE ONLY 7 f Application Accented by , ra - Dare S' Area, - Pit or Grout Inspection by Date Final Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health vervtr.ee; � vp T Environmental health PermitlSerices LJ Lf 445 N San Joaquin, P U Box 2009, Stkn, CA 95201 FEE INF OL AMOUNT DUE AMOUNT Rf MITTED CK M CASHRECEIVED 8Y DATE EEM 13 24 IV1/e�r .. 7!PEliigJfi fP-t74.20 v� 9'! 1-` f1,ILI 4 iI � L