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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 1862 and the Rules and Regulations of San Joaquin Country?Public Health Services. Job Address Cit Lot Size/Acreage Owner's Name �� - `�/ Address `? j `�14,!'fid-u- -�-� Phone flag L,101!2 Contractor r Address cf e License No.�2�Phone2 d TYPE OF WEL PUM : NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Weil ❑ 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 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS nIndustrial C1Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Weil Casing XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public C7 Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done D, Type of Pump�d-1.,� H.P.I&= State ork Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth P*L TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTED I ) iNo septic system permitted if public sewer is available within 206 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. PKG. TREATMENT PLT. ❑ Me. IT Distance to nearest: Well Foundation Property E'iM . F ,n r LEACHING LINE ❑ No. & Length of lines Total length jj FILTER BED 1;1 Distance to nearest: Well Foundation Prp 'Ii � L' ` '�^`"�'i( ' " r I ,— �. Ali i VIYi+JI`I SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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'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 candies 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 a required inspections. Complete drawing on re arse side. Signed X Title: Date: F DEP� �Ly Application Accepted by Date Amm 1A 11r Pit or Grout inspection by Date Final Inspection by Qate�� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 85201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY 9ATE PERMIT' O. EH 14•I6 n CC!!