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APPLICATION } SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION REg%E1W`m01' 445 N SAN JOAQUxN, PHONE (209)468-3420 MAY 1 $ 193 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT MIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete in Triplicate) PERMIT/SERVICES 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r Job Address City Lot Size/Acreage Owner's Name L Address Phone Contraclddres �L[cense N _��2-Pfion TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [7 _/DESTRUCTION ❑ Out of Service Wet1 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR !— OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS (!�n INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �1 ' ❑ Ind trial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing zomestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications I"I Public fa Other n Delta Depth of Grout Seal Type of Grout I I Irrigation ��.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 13 Type of PumprH.P. _ � State Work Done Well Destruction ❑ Well Diameter Sealing )Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION I } iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character ofsoii to a depth of 3:feet: Water table depth SEPTIC TANK. „ '❑ Type/Mf 9 - Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line !f LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED Cl Distance.to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 . I A 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, t shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 compansa• tion laws of California." The applicant must cal foall required i rhqw.ctlons. Complete drawing on re side. Signed Title: l " Date. FOR DEPARTMENT USE ONLY Application Accepted by r✓ � y� Date � Area Pit or Grout Inspection by Date Final Inspection by Date- Additional 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, GA 95201 FEE AMOUNT DUE AMOUNT-REMITTED CK NFO CASH RECEIVED 9Y DATE PERMIT'NO. [n . EH 13-21(REV.I 1 H 51F� �� , EH 1420 1 '7,j