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s APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ',: "" ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 APR ENVIRON' PERMIT EXPIRES 1 YEAR FROM DATE„ISSUED p��lk.� ; J - HEALTH�� (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with Sam Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ' ` Ge City Lot Size/Acreage Owner's Name .a.t1 Address Phone f r q�+��'�, Contract Addre License N �(��— >'hon TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Yell 0 PUMP INSTALLATION U,-' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_ FLD. PROP. LINE FOUNDATION AGRICULTURE WELL- OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Indus not ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing -fi•Domastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications f'l Public f-1 Other f-1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth i I Easternf Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. 1 -- State Work Done Well Destruction ❑ Well Diameter Sealing Material A Depth �. Depth Filler Material i Depth TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i lNo septic system permitted it public sewer is ISS available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. S Length of lines Total length/size (1 FILTER BED 0 Distance to nearest: Well Foundation Property Line i1t�1 SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: 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 rubs 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 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 m II required ins ct ts. Complete drawing on rse side, -�Q Sigma Title: Date:,3 [ OR DEPARTMENT USE ONLY 4� Application Accepted by r Date WVr Area �r Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, O Box 2009, Stkn, CA 95201 INFO FEEAMfOVr#1T D#JE AM�O"U`N�TL1REMtTTED CK RECEIVED BY yj DATE PERMIT'NO. . EH 17.21[REV,I/w 6! P� L�-�.( �..J T L ��~ EH 11.7! e �