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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 its 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 r s� � 6 7 f +� City Lot Size/Acreage / Owner's Name ddress {��H r - Phone .. Contractor Address 3 0� License No.� Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEME T C7 DESTRUCTION 111 Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I"] Public C7 Other fl Delta - �Depth-of Grout Seal - - Type of Grout I I Inigation —,Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H,P. _ State Work Done Weil Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION tV REPAIWADOITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence--L Commercial_ Other Number of living units: _J_ Number of bedrooms Character of soil to a depth of 3 fest: - -Water table depth SEPTIC TANK 0 Type/Mfg. Capacity"_ No. Compartments PKG. TREATMENT PLT. 111 Method sal Distance to nearest: Well ation Y Property Line LEACHING LINE Cl No. 6 Length_of_linesd_ Total length/size FILTER BED 0 bistance to nearest: Well dation !J� Property Line SEEPAGE PITS 11 Depth Sire Number 3 SUMPS Ll Distance to nearest: Well if dation ---- Property Line 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the petiormance 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 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 spillfor all requi , tions. Com t awing on rev side. Signed Title: 7n, ,/[ Date: OR PARTMENT USE ONLY ° Application Accepted by Date 3 Area lieZ 1 _ 1 0 Grout Inspection by ate L �� ls Final Inspection , Date (Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services r 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK C RECEIVED BY DAT5, PERMIT'NO.. . EM 13-241REV.1M 5t EH 11.20 v C/ "e;