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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 I P O BOX 2009, STOCKTON, CA 95201 I 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 frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �/� t s �S .� City of Size/Acreage Job Address — 7Y f �77 Qr Owner's Name Address K� r_ Phone P Contractor Address t License No Phone r i TYPE OF WELL/PUMP: NEW WELL ❑` WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑. SYSTEM REPAIR C1OTHER E3Monitoring Well ❑ Y DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. t PROP. UNE I FOUNDATION1 AGRICULTURE WELL OTHER WELL-- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C_-1 Industrial I ❑ Open Bottoln _© Manteca Dia. of Well Excavation _ Dia. f Well Casing to Domestic lPrivate Gl Gravel Pack Type of Casing— I'] Public Cl Other r ,f7 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx.'Depth c I I Eastern Surface Sedl Installed by Repair Work Done L1 Type of Pump H.P. ____ State Work pone , E Sealing Material & Depth Well Destruction [3 Well Diameter , Depth Filler Material & Depth Depth NEW INSTALLATION I 1 REPAIHIApDITIQN DESTRUCTION l I (No 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 of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ i Method of Disposal } �1 Distance to nearest: Well Foundation Property LineOF LEACHING LINE ❑ No. & Length of lines /�, gTotal length/size S f Distance totnearest: -Weil Foundation sem— Property Line v FILTER BED � .� SEEPAGE PITS 11 . Depth Size Number SUMPS ! Ll Distance to"nearest: Well Foundation Property Line {s f 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 lCounty 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 r employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or subcontracting signature..-• certifies the following: ,'I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." The applicant must call for 1 req d inspifiVions. Complete drawing on re�lq side, Q Signed Title: Date: - { FOR DEPAR MENT-US NLY-�.,r'� ARplicati6n Accepted by�' Date Area - . Date Inspection b .Pit or Grout inspection by Date.` Final tns� y "Additional Comments: Applicant`-_Return all copies to: San,Joaquin County Public Health Services g Environmental Health..Permit/Services s i 445 N San Joaquin, P O Box 2009,, Stknj CA 95201 t tE MOUNT DUE AMOUNT REMITTED CK CEIVED BY DATE PERMIT NO. r . EM 15-24{REV.tiA5; �[b a EH 14.20