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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION S 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA. 95201 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l (Complete in Triplicate) Application is hereby made to Saul 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 County Public Health Servi s. //�� Job Address J� "' __ City - Lot Size/Acreage df 4k_ _ {� Owner's Name y ' � Address Sz-. e_ Phone Contractor t ddress �07 License No. a SPhone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA&MENT 177 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U 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 ❑ Industrial ❑ Open Bottom .0 Manteca Dia. of Well Excavation Dia. of Well Casing EI Domestic/Private ❑ Gravel Pack7 ❑ Tracy` + Type of Casing_ Specilications F) Public (1 Other n Delta 5. Depth of Grout Seal Type of Grout I I irrigation —Approx. Depth }I I Eastern Surface Seel Installed by - Repair Work Done L] Type of Pump H.P. ` State Work Done ' ling Material fr Depth Well Destruction ❑ Well Diameter Seeding , Depth Filler Material i Depth It TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted A public sewer is UA available within 200 feet.l (� Installation will serve: Residence--)(- Commercial Other �. - ` f Number of living units: _ — Number ofsbedroorrns Character of soil to a depth of 3 feet: / f£]/DC7 _ _ ` Water table depth ` SEPTIC TANK. ❑ Type/Mfg t� f��S�— v/ Gapacity � No.Compartments PKG. TREATMENT PLT. ❑ �/ •, ' `" . s Method of Disposal' Distance to nearest: Well [ .Foundation �--. _Property Line ' LEACHING LINE W No. & Length of lines Total length/size FILTER BED l ❑ Distance to nearest ell j Foundation' s Property Line�--- SEEPAGE PITS Depth Size Number 79_Z2 SUMPS k - - LI'-Distance to nearest: —.,Well _..- Foundation Property Line DISPOSAL PONDS ❑ J ' ' •_ I hereby certify that I have prepared this application and that the woik will be done in accordance with San Josquin"county ordinances, state laws, and rules and regulations of the San Joaquin County 71 r1, 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." e ThF applicant must call.for all requir i Oction4ornplete drawing on reverse side. If- FOR DEPARTM NT USE ONLY E_ Application Accepted by < Data Pit or Grout Inspection t Date F ;Fi` I 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, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CKO AECEIVEO 9Y DATE PERMIT'N0. . Ek13-24(REV.it K si �- EM 14.26 i