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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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 made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Publics Health Services. Job Address W l- j �-----"-r.,D� City Lot Size/Acreage Owner's Name r Address 4?6J Phone �� r Contractor AddressCirL License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM P IR ❑ OTH % Monitoring Well ❑ NYAN TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD ROP. LINE/ FOUNDATION 6 AGRICULTURE WELl7r OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio�ffi Dia. of Well Casing ly Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications ` . Other )R(Delta Depth of Grout Seal Type of Grout Y III �Approx. Depth l I Eastern Surface Sed] Installed by'' �� Repair Work Done U Type of Pump H.P. ___— State Work Done Welt Destruction ❑ Well Diameter Sealing Material & Depth �t Depth Filler Material A Depth V TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.] 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 I A Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Isl Foundation Property Line , LEACHING LINE Cl No. & Length of lines Total length/size (b FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth SizeIX/ I Number SUMPS LI Distance to nearest: Wei 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, 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 must call for I require inspec ns. Complete drawing on reverse . C Signed Title: sid Date: � FOR DEPARTMENT USE ONLY Application Accepted by `^-� date Araa Pit or Grout Inspection by Date Final Inspection by Date Z� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services a]?TO '1j F Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO NCASH . EM13.241RFV,11-Si Qqi atat(—' Q� ,�Q �V �t0 �y -1 `2•;� S3 �3"�1p�p EH 14.20 v V �]