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{ .. � APPLICATION SAN JOAQUIN COUNTY PUBLIC HE HS###ICES�?�_� ENVIRONMENTAL HEALTH DI T ION � 445 N SAN JOAQUIN, PHONE (20 42 P O BOX 2009, STOCKTON, C 9`5' 01 PERMIT R IRES 1 YEAR FROM D TE�� (Complete in Triplic Application is hereby made to San Joaquin county for a permit to construct an or n ( 1 application is made in compliance with San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of an Joaquin County Public Health Be00 r ices. � Job Address !r CA r j + Ciittyy Lot 81ze/Acreage Owner's NameddressG.B[ --5 Phone Contrac o 00YIM�y�l Q �Addre s _aJ as License No. hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT !71 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Welt Casing .-sbDomestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_ Specifications I-I Public El Other r Delta Depth of Grout Seat Type of Grout I I Irrigation _.Approx. Depth I Eastern Surface Sedl Installed by - Repair Work Done L7 Type of Pump C1 P. _ State Wo k Don 0 Well Destruction ❑ Well Dia to Sealing Material 3 Depth Depth Filler Material & Depth r 0` TYPE OF SEPTIC WORK; NEW INSTALLATION f I REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted it public stlwer i Installation will serve': Residence— Commercial available within 200 feet.) Other C t� Number of living units: Number of bedrooms', Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. `D 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/site FILTER BED n Distance to nearest: Well Foundation Property Line ..SEEPAGE PITS 11 Depth Size Number "` SUMPS Ll Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Lina 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 iihe San Joaquin County Home owner or.ficensediagent'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."Contractors hiring or sub-contracting signature certifies the following: "I certify that in theperformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." Thea plican�mut �f�r �ruir �specti�onsmplete drawing on re rse side. Signed Title: f O Date: FOR 'DEI�ARTIMENT USE ONLY r l - Application Accepted by pate Ares 2 11 i Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to; San Joaquin County Public Health Services V-� Environmental Health Permit/Services V- 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO L7_ CgASH RECEIVED BY DATE PERMIT'NO. . EH 13.21 tREV.rix61 V .�•n� }�� !V f :��3�641lars •.••� EH 13-26 )z) i��./