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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 200911, STOCKTON, 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin CountyPublicHealth Services. xJob Address ` �&r_2 �� -v��" �9 - City,__�d Got Size/Acreage XOwner's Name eS- LR D tAddress C55 �� _ Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION o Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER p Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f_7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing._ Specifications I'1 Public Ia Other n Detta Depth of Grout Seal Type of Grout 1 I Irrigation Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H,P. _—_ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth l`I Depth Filler Material & 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 1 i REPAIRIADDITIO DESTRUCTION fNo septic slam permitted if publi er is i v ithin 200 feet.) tallstion will serve: Residence— Commercial— Other I Numbe ving units: Number of bedrooms Character of sot depth of 3 feet: - Water table depth SEPTIC TANK ❑ /Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: ell ndation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED Cl Distance to Well Foundation �ropsrty ' SEEPAGE PITS Ieplh Size Number_ SUMPS Ul Distance to nearest: Well Foundation Property Line i DISPOSA NDS ❑ I y 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 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, I shall employ persons subject to workman's compensa- tion lows of California." The applicant must call for all required ' ctions. Complete drawingo se side. XSigned Title: �C.c.✓1� rl�.� --,-- Date:, i DEP RTMEf11T USE QNLY S Application Accepted by L ate . _ Area Z 1 v Pit or Grout Inspection In Date Final Inspection by Date Additional Comments: Applicant - Return all copies, to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMO T DUE AMOUNT REMITTED CASH��y��777 ST EIVED BY D E PERMIT'NO. . EH 13.24 IREV,r i M SI S• EH 114.26 - /// ��