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APPLICATION Ak ,� . -- •"� rAN JOAQUIN COUNTY PUBLIC HEAL at -� ENVIRONMENTAL HEALTH DIVISIO j} 445 N SAN JOAQUIN, PHONE (209)4634 P O BOX 2009, STOCKTON, CA 952p1# PERMIT EXPIRES 1 YEAR FROM DATE ISSNED (Complete in Triplicate) Tr ■ 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. // Z�3 ��—/�� T CityLGd5Z4o g Job Address Lot Size/Acres e Owner's Name fN �C J /« Address �-Z_ � N. �4� I_0J Phone Contractor 1 � �� __%address/�2 I" License No. Z 6�Phor 6 7 012-7 TYPE OF WELL/PUMP NEW WELL O WELL REPLACEMENT 11 DESTRUCTION O Out of Service Well O PUMP INSTALLATION C SYSTEM REPAIR - OTHER 0, Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. PROP. LINE —.SOI FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ •1_t1C b c N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J75Ii C� Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` C 1 Domestic/Private ❑ Gravel Pack Ll Tracy Type T of Casing.._- Specifications t ---- I'I Public 11 Other 1-1 Delta Depth of Grout Seal Type of Grout I i IrnUauon __ Approx. Depth I I Eastern Surface Seel Installed by Repair Work Done U Type of Pump H.P. —__— State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK. NEW INSTALLATION ' 1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Omer _ Number of living units: Number of bedrooms _- Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines -_ Total length/size FILTER BED C) Distance to nearest: Well _ Founaation Property Line SEEPAGE PITS 11 Depth _ Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 workmen'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 m t call for all r uired inspa tions. Complete drawing on reverse side.. Signed X Title: IC LI FOR DEPARTMENT USE ONLY Application Accepted by — Date Area Pit or Grout Inspection by Date Final Inspection by / ate al Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services �1 Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERIM17 N0. • EH 13-21(REV,r i n 3) � L EH 11.20 b (i