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APPLI CAT I'ON SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 3 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ► I P 0 BOX 2009, STOCKTON, CA 95201 5 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (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. )f xj��N I , �e Job Address O 4 r u City , Lot Size/Acreage € �? +l / Owner's Name iidr`ess, Phone, i Contractor Address % License rlo Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 177 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR C7 t OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL e PITS/SUMPS r i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation T i T Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack%. ❑ Tracy Type of Casing_ Specifications to Other s n Delta Depth of Grout Sea[ * Type of Grout V1 1 Public ? F i I Irrigation Approx. Depth I I Eastern Surface Seat Installed by e f Repair Work Done 0 Type of Pump H.P. _�— StatB Work Done1. _ �k Well Destruction ❑ Well Diameter Well Material 3 Depth t 1 Depth Filler Material d Depth TYPE OF SEPTIC WORK: NEW INSTALLATION C -REPAIR i I DESTRUCTION I I (No septic system permitted if public sewer is J available within 200 feet.) Installation will serve: Residence! Commercial _ Other W_NumE>er oi_jiving�un,�[s:,,_,.r� Numbe�of bedrooms�_ e _ � � s Character of soil to a depth of 3 feet: Water table depth a SEPTIC TANK ❑ Type/Mfg !C No.No. Compartments ;PKG. TREATMENT PLT. ❑ ��_ Method of Djaposal } Distance to nearest: Well &&oundation , Property Line U_& LEACHING LINE No. A Length of tines J`tal length/iize S IFILTER BED ❑ Distance to nearest:_ —Well ... = Foundation Property Line v SEEPAGE PITS Depth M ASize r Number SUMPS Ll Distance t0-nearest: a WeIL tion Property Line t 'DISPOSAL PONDS ❑ �tom' h s it hereby certify, that I have prepaied`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 Y. f ,Boma owner or licensed agent signature Certifies the}ollowing:TM•I_Certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner a4to b=come subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature Icertifies the follovtrini!41 certiiy.that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- 3tion laws of Cajitornla." A—* } t Jins applicant 11 for all req r'd I spe.ctions. Co pl a drawing on.reverse side. 3�f 7 1 'Signed Title: �" — _ Date:: z FOR DEPARTMENT USE ONLY `.�• /fij e �/ ~ `Il/' ,Area� T. .; ?� Application Accepted byDat •';r i t -JPit or Grout Inspection by a Date Final In pection y Date r T '•f` Additional Comments: ' "'""ApplicanE'='Retu`Tn alZ'oopies'toi' San Joaquin County-Pu6Iic Health-'services "" W `a- Environmental Health Permit/Services ` ^ ^�- `� 445 N San Joaquin, P 0 Box 2009, Stkn-, CA 95201 FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. �:...,� EN 17.24 IREV.ii n �.v� ' l f V• �_` EH 14.20 c t9