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�- APPL I CAT�OR PERM I T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION REUMInD 1601 E. HAZELTON AVE, , PHONE (209)468-3420 J u N P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH EXPIRES 1 JEAR FROM DATE ISSUED PERMIT/SERVICES (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to application is made in compliance with San Joaquin County Ordinance nNo. 549 and etruct o18628and the tall eRules and vork eRegulations in dof Sans Joaquin County Public Health Services. f l Job Address City U6L— Lot Size/Acreage Owner's Name dress _ Phone 44 �✓ J/ ra f No. Phone C r ct TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS "" INTENDED USE-----cTYPE'OF-WELL PROBLEMA`REA"-CONSTRUCTION SPECIFICATIONS - n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing l testic/Private ❑ Gravel Pack I-] Tracy Type of Casing Specifications f !"1 Public 1-1 Other`s t fl Delta Depth of Grout Seal Type of Grout a. I (,Irrigation �,.Appr%ox.'Depth I I E t o ace Seal Installed by Repair Work-Done-0- Lf Type of Pump H.P, S to r e w Well Destruction ❑ Well Diameter - _rrd Sealing Material & Depth r is 'DVpth° Filler Material & Depth r TYPE OF SEPTIC-WORK:`�NEW INSTALLATION I I REPAIR/ADDITION I f DESTRUCTION I I (No septic system permitted if public se7is` r. available within 200 feet.IInstallation will serve: Residence Commercial— OtherNumber of living units: Number of bedroomsCharacter of soil to a depth of 3 feet:' Water table depth 3 SEPTIC TANK. ❑ Type/Mfg. ` Capacity No. Compartments PKG. TREATMENT PLT. C] Method of Disposal Distance to nearest: Well Foundation Property Line"2 I LEACHING LINE ❑ No. & Length of lines Total length/size ' h FILTER BED ❑ Distance tornearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size^� Number SUMPS LI 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-with_San-Joaquin county ordinances;state=laws,-arid- ^�roles e� r9gulehons o t e an oaquin 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 Californi The applic m st call r Wired i sp ec tions. C plate drawing on Peva a side. Sign d / Tit( r J Date: OR DEPARTMENT USE ONLY Application Accepted by �� Date 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 ' 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO L/ ,y/) CASH DATE PERMIT'NO. + EH 13-24(REV.Iinsl R 736&v �. /� �� i EH 7I-2e VVV `]�,