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APPLICATION �c,C . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT F,gPIRES 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 County Public Health Services. S�4 /� City)C DIL Lat Size/Acreage Job Address Address � — Phone Owner's Name — License No. Contractor — �Phon�f NEW WELL ❑ WELL REPLACEME T C] DESTRUCTION ❑ Out of Service Kell L-17 OF WELLlPU P: PUMP INSTALLATION C7 SYSTEM REPAIR ❑ OTHER C7 Monitoring Well C7 1 DISTANCE TO NEAREST: SE SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION RICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Pie. of Well Exc Dia. of Well Casing n Industrial _ Type of Casing_ Specifications L7 Domestic!Private ❑ Gravel Pack L] Tracy of Grout ["I Public Cl Other P Delta Depth of Grout Seat Pe 11 Irrigation r Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done v Type of Pump H.P. State Work Done Sealing Material b Depth Well Destruction ❑ Well Diameter Filler Material 8 Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTIO (Nsitseptic systeshin 200 feet.) m Installation will serve: emitted if public sewer is Residences Commercial Other Number of living units: _,A'2 Number of bedrooms Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.ElMethod of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Weil Foundation Property Line SEEPAGE PITS it Depth Size Number \� SUMPS LI Distance to nearest: Welt Foundation Property Line l DISPOSAL PONDS ❑ 1 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 subcontracting 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." The applicant us call all re ua ctions mplete drawing on reverse s' e. Title: Signa Date: ..- FOR DEPARTMENT USE ONLY r / Application Accepted by Date Area Pit or Grout Inspection by V Date .Final Inspection by Dater `� 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 FEECASH CK RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DUE AMOUNT . .d E13.24IREV.rixsl S 6..J , /7REMITTED r �D Ylab 3i OJ P EM 747e - .