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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 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 made in compliance with Sara Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San t Joaquin County Public Health Services. ' i Job Address m f City .fl Lot Size/Acreage �' �� Owner's Name ..— � Address _.,., ��- - �`� Phone • Contractor— -► c _ Address License No.; �'l�t Phone $`- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION -"-AGRICULTURE WELL.. TOTHER.WELL. -PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial \ 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f:1 Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_ Specifications Il Public 'Cl Other n Delta Depth of Grout Seal Y Type of Grout I I Irrigation ._._, Approx. Depth I 1 Eastern Surface Seal Installed by s Repair Work Done ® Type of Pump H.P. State Work Done R^ Well Destruction CJ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION LX_ IRIADDITION f I DESTRUCTION I i INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commerci Other f Number of living units: ! Number of bedrooms—.--�-- - t Character of &oil to a depth of 3 feet: l.�+r+in-' - .[ � _ Water table depth SEPTIC TANK. i8- Type/Mfg �+'L"�' 'T��f11 _ Capacity__. No. Compartments 1 , PKG. TREATMENT PUT. ❑ Method of Disposal �. Distance to nearest: Well _._ _ Foundation c u Property Line 100 LEACHING LINE Of— No. & Length of lines c30 41po Total length/size FILTER BED n Distance to nearest: Well- ]1".2 _ Foundation MZ) r Property Line 102 SEEPAGE PITS tOI— Depth =� � Size z l ` Number _ r SUMPS LI Distance to nearest: Well Foundation Property Line_ fO DISPOSAL PONDS El 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, 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 cenifies 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 must ca for all require ns ctions. Complete drawing on reverse side. Signed Title: . !)Le�t�I "�° Date: I OR DEPARTMENT USE ONLY I ` P'1 �I Application Accepted by __�� Cil.4r its - Date ti _ L 0� � Area 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 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASN RECEIVED BY DATE p PERMIT'NO. . EH 13-241REV.I/Hss f r] r � 1I~/o~/ ` �36 ` EM 1/-2s rPVV