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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.0rdinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ` /� A /Tao �i r L f City_ Lot Size/Acreage ,- �{ .a— — Job Address f ' �J� `` 5C:U !J � Owner's Name 0 1 ddress Phone TAY— _-Addre ,p __ Phone .... .� -. _ _ ss ��-•D-I - Lscensa tro. ' `� 'Contractor TYPE OF WELL/PUMP: NEW WE1 WELL REPLACEMENT Cl DESTRUCTIONMonitoring well L] ❑ Out of Service well ❑ 0TH ❑ PUMP INSTALLATION E3 PROP. REPAIR ❑ t PROP. LINE DISTANCE TO NEAREST; SEPTIC TANK O^f SEWER LINES _ DISPOSAL FLD. FOUNDATION � AGRICULTURE WELL �� OTHER WELL PITSlSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing C1`Industrial pen Bottom ❑ Manteca '� Dia. of Well Excavation +� Type of Casing— Specifications i omestic/Private ❑ Gravel Pack ❑ Tracy yp 9; Type of Grout'�� I'1 Public Cl Other Cl Delta Depth of Grout Seal -1"1 itiigation Approx. Depth t I Eastern Surface Seal Installed by Repair Work Dane L] Type of Pump H.P. State Work Done O ` Sealing tial & Depth Wel! Destruction C1 Well Diameter Filler Material & Depth ` Depth _ TYPE OF EPTIC RK: NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION I I (Noavasapttilable cystithin m emitted if public sewer is Installation will serve: Residence Commercial — Other Number of living;units:� `' '_ Number of bedrooms Character of soli"to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg, Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of tin Total Iengthlsize FILTER BED' �"` ❑' Distance to nes t: well Foundation - Property Line I SEEPAGE PITS 11 Depth Size Number r_ SUMPS L I Dist co to nearest: Well Foundation Property Line r DISPOSAL PONDS ❑ I hereby certify that i p p have we this application and that the work will be done in accordance with San Joaquin coujlty 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 workmen's"compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: " can 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 wire in tions plot.drawing on reverse side �� Signed X itle: �4rr� Date: FOR DEPARTMENT USE ONLY 1 1 Ap t is ion Accepted by Date Area 2-` 4G--�1� Pit�r"r t inspection by at. a Final Inspection by Date Ad bonsi 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 AMOUNT DUE AMOUNT REMITTED - RECEIVED BY DATE PERMIT'NO. yINFO . EH 13-24t Ev.t/x s! EH 14-26 �J