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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I 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 cemllemce with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ;3wa toCity fit Lot Size/Acreage Owner'sName dress '' Phone + Contractor Address License No.-cc!A� Phon V 0 TYPE OF WEL PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER " Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C-} Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public is Other FI Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth i I EasternSurface S i In tailed by Repair Work Done 06 Type of Pump, H.P. t _ Stat Work D Well Destruction ❑ Well Diameter Sealing Material to Depth .�_&W * t Filler Material & Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.f 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. ❑ Type/Mfg Capacity No. Compartments 1 PKG. TREATMENT,PLT. Cl _ Method of Disposal N Distance to nearest: Well Foundation Propen LEACHING LINE Cl No. & Length of lines Total length/ rp FILTER BED ❑ Distance to nearest: Well Foundation PropgW.LinQ9 1992_ SEEPAGE_ PITS 11 Depth Size NumbfxL;.�3� u nl Ts .a c��trlrr�c SUMPS r CI Distance to nearest: Well ~Foundation Vrtiii@ ria'�, DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be dons 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 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." The applicant ust call for al uired inspections. Complete drawing on reverse side. ,�-� 2 Signed TItIe: �tn tz��rs-,� . --- pate: r• DEP RTMENT USE ONLY q Application Accepted by Date C��- ea Pit or Grout inspection by. Date Final Inspection by Date f Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ATE PERMIT"NO. fI�NFO CASH I FH 13-24 IREV. /n Si Y5 rQ 0 C� I EH t4-2e I 1+�� -1?3z 1