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r 6? "50 APPLICATION �3 �r SAN JOAQUIN COUNTY PUBLIC HEALT ENVIRONMENTAL HEALTH DIVISI G 'a 445 N SAN JOAQUIN, PHONE (209).163 4 0 P O BOX 2009, STOCKTON, PERMIT EXPIRES 1 YEAR FROM DATE F1, (Complete in Triplicate:' .i 1, ., Application is hereby made IMA to San Joaquin County for permit to construct and/or 11 tM F►e,ra or 4h,eri Thi F application is made in compliance with San Joaquin County Ordinance No. 549 and '1862 Joaquin County Public Health Services. Job Address �� } ®t Jsl_ - City sTick Lot Size/Acreage N r Owner's Name Address Phone !� Contractor Address ,S 71<,*%) � L! __ License No. l Pti'one TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT R DESTRUCTION ❑ out of Service Well ❑ t-- - - r PUMP INSTALLATION GTS SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing C. omestie/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 11 Public Cl Other 11 Delta Depth of Grout Seal Type of Grout ! I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. _ � �_ State Work Done F Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth C2S1 �497 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i fNo septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence_ Commercial Other r ° Number of living units: Number of bedrooms q 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 i FILTER BED ❑ Distance to nearest: Well Foundation Property Line /1 �+ SEEPAGE-PITS [ I Depth Size Number , 1 t + SUMPS LI Distance to nearest: Well Foundation Property Line /Y DISPOSAL PONDS ❑ 1 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 Sen 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 call for ail required ins ctions Complete drawing on rse e. Signed X Title: _--- —_� ��L: Date: FOR DEPARTMENT USE ONLY Application Accepted by _ a Date AN A r a f Pit or Grout Inspection by Data Final Inspection by Data Additional Comments: Applicant _ Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services l 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 ! - - , i� �; t.«? � gr �P �i''�w<„ - , r�- �-� f'�"Ef.r- '� � � �+� e�^�•riN.�'