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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 2009, 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 County Public Health Services. r- Job Address I eA , City ( r Lot Size/Acreage Owner's Name i Y 1 1�.:� s W Z!1`1 Address i E " Phone Q� Contractor Address License No. a _Itn1 Phone TYPE OF WELL/PUMP: ,NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION o Out of Service. Well ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring 41e11 ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE,.WELL OTHER WELL - PITS/SUMPSy INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiFICATfONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private Gl Gravel Pack C1 Tracy Type of Casing_ Specifications \ 11 Public M Other n Delta Depth of Grout SeatType of Grout 1 �aIrrigation _.Approx, Depth 11 Eastern Surface Seal Installed by rN pair Work Done U Type of Pump H.P. 0 State Work Done Well Destruction ❑ Well Diameter = Sealing Material S Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 11; REPAIR/ADDITION I i 'DESTRUCTION I I INo septic system permitted it public sewer is P A YMM�ple within 200 feet.) Installation will serve: Reside_ Commercial— Other RECEIVED lJl Number of living units: Number of bedrooms 4.r Character of soil to a depth of'3 feet: MAY I naMater table depth SEPTIC TANK ❑ Type/Mfg Capa5 B J�p mp�artrnenta PKG. TREATMENT PLT.❑- PUBLIC HEALTH SER of Disposal Distance to nearest: Well FourEN RONMFNTAt • t LEACHING LINE Cl N6.A Length of lines Total length/size FILTER SED ❑; Distance to nearest: Well Foundation Property Line l � SEEPAGE PITS I I� .Depth Size Number ` SUMPS Cl 9:_Distance to nearest: Well Foundation Property Line - �- - 5- DISPOSAL PONDS ❑3" 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 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 laws of California." Contractor's hiring or sub-contracting signature certifies the follovv'ng: 'I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- tion laws Cal' rnia." The applict t call for all r 4-red'inspeetiops. Complete drawing on rev rs side.lal Signed Title: ` Date: -4 -2 -- FOR-DEPARTMENT USE_ONLY - t f Application Accepted by ` D'ate' Area Pit or"Grout Inspection by Final-!inspection by Date Additional Comments: l� } I Applicant - Returnfall copies to:' San Joaquin County Public Health Services '- Environmental Health Permit/Services ' # ) 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE' AMOUNT REMITTED CK ECEIVED BY D TE PERMIT NO. INFO . EN 13-24(REV.i/NSI P EH 1620 I�� i