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APPLICATION r 'USAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES + 1 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 / P O 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 Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. / Job Address aW Ys- + r City�Zoelj' Lot Size/Acreage Owner's Name � z ill Address Jl� .,� � it1r 1Y Ifl Phone _LCL V�J nh �^+ Contractor r' Address ��' ! HSGs License No. alt Phone r ~ TYPE OF WELL/PUMP'. N W WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIOTHER ❑ Monitoring Well C] v 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 ID Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing c� ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public El Other E-1 Delta Depth of Grout Seal Type of Grout 4 Irrigation _ Approx. De th I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump L H.P. State Work Oone �4,ef ,r�'4-'m,4, /frdf t Well Destruction ❑ Well Diameter Seelin8 & Depth .=,•r � /� r 9" � Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIWADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 Teet.1 Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 test: Water table depth t� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments (1,, PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line tA LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 11 Depth Size Number SUMPS 11 Distance to nearest: Well Foundation 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'a signature certifies the following: "I certify that in the peiformance 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 must call for all required inspgctions. Complete drawing on reverse side. Signed X Title: dttPxt+_ Date:o FOR DEPARTMENT USE ONLY Application Accepted by _._ Date /InAree Pit or Grout Inspection by Date Final Inspection by� !1 Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, O Box 2009, Stkn, GA 85201 rr IN FEO AMOUNT DUE /AMOUNT REMITTED CK�H} RECEIVED BY DATE 4PERMI7,NO. . EH 13-24(REV.t i sl I1 f� O 6 T L14-0r �ld p� �!v- �� ✓ /� �. EH t{•2a r