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APPLICATION 7 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES N O _. /� A f ENVIRONMENTAL HEALTH DIVISION ju 445 N SAN JOAQUIN, PHONE (209)468-3420 " P O BOX 2009, STOCKTON, CA 95201 Na l/ PERMIT EXPIRES 1 YEAR FROM DATE ISSUID { (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. s application is made in compliance with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations oT San Joaquin County Public Health services. i hC City Lot Size/Acreage Job Address "y �EiS Address Phone Owner's Name g S "Canhactor Sa� Address _ License No. Phone TYPE Of WELLIPUMP: NEW WELL ❑ y WELL REPLAGEMEfVT' C1 DESTRUCTION ❑ out of Service.Kali ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring well L1 DISPOSAL fLD. PROP. LINE ^ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES FOUNDATION AGRICULTURE WELL.-. OTHER WELL-- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Type of Casing_ Specifications ['.I Domestic/Private ❑ Gravel Pack i ❑ Tracy Type of Grout [1 Public Cl Other Ll Delta Depth of Grout Seal r � i I Irrigation —Approx. Depth ; I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done �� Sealing Material & Depth 1 Well Destruction ❑ Well Diameter Filler Material & Depth Depth TYPE OF SEPTIC WORK. NEW INSTAL I+ I I REP AIR/ADDITION I ml- DESTRUCTI (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Resid ince Commercial_ Other Number of living units: Number of bedrooms--,AO-- Character of soil to Bath of 3 feet: ` Water table depth SEPTIC TANK. ❑ Type/Mfg Capadity""' "� "` No. Compartments PKG. TREATMENT PLT..❑ Method of Disposal Distance to nearest: Well Foundation E Property Line LEACHING LINE ❑ No. & Length of lines; Totaklength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 3 SUMPS LI Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS ❑ i 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, I 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 taws of California.•' Contractor's hiring or sub-contracting signature certifies the following:"I comity 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 applica must call for all r uired in�.ctiornis- lete drawing on reverse side.-;C ,Signed Z7- Title: 0G✓' Date: FOR DEPARTMENT USE ONLY i S cS Date ~!� � Area ` . Application Accepted by ? Pit or Grout inspection by Date Final Inspection by Date J Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services r Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95201 FEE CK RECEIVED BY DATE PERMIT'NO. INFO AMOUNT DeIE AMOUNT REMITTED CA5H �1 � EH 13 241(REV.r i n si EH I6]e