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APPLICATION �+� r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 �� P O BOX 2009, STOCgTON, CA 95201 N-0 'B,L: PERMIT EXPIRES 1 YEAR FROM_ DATE _ISSUED (Complete in Triplicate)} µ Application is hereby made.to San Joaquin County for a permit to construct end/or install the work herein described. This application Ie made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. i r r� in Job Address I ity Lot Size/Acreage tDo#,A 6 wner's Name Address -YC_�_I -1 Phone ontractor W Address. License No. Phone. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC ENTn DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION 0 S, EPAIR _I OTHER 0 Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK 5E eR LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRI LTURE ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA C NSTRUCTION SPECIFICATIONS fl industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing f.l Domestic/Private 0 Gravel Pack n Tracy Ty of Casing_._ Specifications 4— I'I Public i-1 Other fl Delta Depth f Grout Seal Type of Grout t I Irrigation ._.,...Approx. Depth I I Eastern Surface ul Installed by Repair Work Done U Type of Pump _ P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i th V, Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAtRIADDITION I I DESTRUCTION (No septic system permitted it 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, M Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED (a Distance to nearest; Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS L1 Distanoe to neatest; 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 ruies and regulations of the Sen 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 corlifies 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 m st call for all rs r spections. Complete drawing on reverse side. r Signed Title: Date: O�DEPARTMENTSE ONLY Application Accepted by �„ d � pate Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 995 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK T RECEIVED BY DATE gPERRMIT'NO. EM 3,24 24IREV,trNs1 EH - �,� V ct�(� 7}�, l J" 01 _ S