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APPLICATION Y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESy ENVIRONMENTAL HEALTH DIVISION # 1445 N SAN JOAQUIN, PHONE (209)468-342W. "'i x:. P 0 BOX 2009, . STOCKTON, CA 95201 PERMIT MIRES 1 YEAR FROM DATE ISSUED'° (Complete in Triplicate) Application is hereby made to San IJoaquin County for a permit to construct and/or install the work herein described. This application is made in compliancelvith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. ff � Job Address / �_3�Q_ City Lot Size/Acreage c ('E Owner's Name Address —Xa:5L _ Phone Contractor -Address n s e No. � [Phone ef TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT n- -DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring well L3 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 L7 Industrial ❑ Open Bottom 0 Manteca Dia. of Weil Excavation Dia. of Well Casing EI Domestic/Private 0 Gravel Pack' L] Tracy Type of Casing_ Specifications F) Public 1:1 Other n Delta Depth of Grout Seal Type of Grout I i Irrigation —Approx.,Depth I I Eastern Surface Seal Installed by y Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth t Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIONX No septic system permitted it public sewer is vailable within 200 Ieet.1 Installation will serve: Residence—.�Commercial_ Other ' is Number of living units: Number of bedrooms Character of $alt to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line } i LEACHING LINE D No. & Length of lines '`` Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS . I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 A A 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 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." 1 The applicant us r r inspections. Complete drawing on reverse side. , Signed X Title: Date: --�JL DEPARTMENT USE ONLY Application Accepted by "��"� _ Date Area Pit or Grout Inspection by Data 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 0 Box 2009, Stkn, CA 95201 INFO FEE MOUNT DUE AMO'UN/T REMITTED CASH REED By DATE PERMIT'NO. . EH 13.2 [REV.iiKSiCH 14-20 •+ar