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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION N 0 1� 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 N 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 vork herein described. This application Is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ss s" 3 City t Size/Acreage GrpOwner's Namen&9?4y-Address Phone IV Contractor Address '^^ License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 Monitoring Well C7 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 EI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i"1 PuhliC M Other fl Delta Depth of Grout Seal Type of Grout I i Irrigation _Approx. Depth I 1 Eastern Surface Sed] Installed by Repair Work Done 0 Typeof Pu/rte H.P. State Work Done p R Well Destruction ❑ Well D' mrd Iter Sealing Material i Depth V Depth Filler Material i Depth l (� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is \ available within 200 Test.l Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of$feet: Water table depth SEPTIC TANK ❑ Type/MfgCapacity 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 n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state qanndrules 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, sanot 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 for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required nspections. Complete drawing on reverse side. Signed X Title: —� ,s:, _ _ _ Date: � t34T F ARTiIAENT USE ONLY Application Accepted by Date 3-3 V�'3 Area Pit or Grout inspection by 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 AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. ov �� - 7 • EM 13.241 REV.1in5) -7 Y �� EH 14-20