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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 4 P 0 BOX 2009, STOCKTON, CA 95201 � :-✓ ' PERMIT EXPIRES 1 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 Imflde in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public HealthServices. '` Job Address _ � r City�A'`� Lot Size/Acreage 100 >e Z 7 Q ' Owner's Name ^S_ �t`9li �2� rL Address �r l] "57L- Phone 4Z-021 ` Contractor < ff`�! (� Address az& v/ JT License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 177 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 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 f-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private Cl Gravel Pack L7 Tracy Type of Casing Specifications I'I Public f_1 Other fl Delta Depth of Grout Seal Type of Grout i i I Irrif)ation _ Approx. Depth I I Eastern Surface Seal Installed by i Repair Work Done 0 Type of Pump H,P. State Work Done _ ` Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material 5 Depth [ TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION f I DESTRUCTION 34,,1No 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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 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, 1 shall noi .=i. 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 Californ The applicant mus a for all req Y d inspec ' mplete drawing on reverse side.. / ~ Signed X Title: l/ Date: R DEPARTMENT USE ONLY 1 ` Application Accepted by _ Y Data L Z �0 Area lr. .� _ T . f Pit or Grout Inspection by Date Final Inspection by Additional Comments. U Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT pt1E AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT"NO. • EH 13-24 IREV,riesYEH 111-M E