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APPLICATION II SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVISION 445 N SAN'-JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i f PERMIT EXPIRES1 YEAR FROM DATE ISSUED i .T;ftplicate). i Application is hereby msde•to San Joaquin County for a permit to construct and/or install the work herein described. This application is Slade in compliance with San Joaquin County,Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County PublicHealthServices. Job Address aQ City Lot Size/Acreage Owner's Name r I CoAddress � r - l �t Q Phone Contractor 0:5 Address d License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION 10 Out of Service Well ❑ ! PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER Q Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS, 4 INTENDED USE TYPE OF WELT PROBLEM AREA CONSTRUCTION SPECIFICATIONS f-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ _ Dia. of Well Casing Cl Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing— Specifications I'1 Public- L-1 Other Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx.tDepth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H. 1 �( State Work Done,_ Well Destruction 7'� Well Diameter (Z• Sealing Material & Depth Depth . �,� Filler Material & Depthy r, d TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I I (N6 septi s tem permitted if public sewer is available within 200 feat.) Installation will serve: Residence Commercial_ Other r Number of living units: . Number of.bedrooms Character of soil to a depth of 3 feet: f Water table depth SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments PKG..TREATMENT PLT. ❑ i it ' r & Method of Disposal 'Distance to'nearest. ':Well ' Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance tp nearest: Well Foundation Property Line r1 '� SEEPAGE PITS 1.1 Depth { Size Number SUMPS Ul Distance tot nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 following: "l certify that in the:performanee of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicint.must call for all required in ctions, Complete drawing on reverse side. Signed X Title Date: Z. D T USE ONLY Application Accepted by «- = Z Q Date Area Pit or Grout Inspection by Date Final Inspection by Data �tv Q� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services I Environmental Health Permit/Services 445 N'San Joaquin, P O Box 2008, Stkn, CA 95201 FEE AMOUNT DtJE AMOUNT REMITTED INFO �� ASR RECEIVED BY DATE PERMI7'N0. ! . EH13-7SIAEV-iiHs 4•Ie (�7/EH 1 v C> 32r.