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LPAPPLICATION v, 5AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NT ENVIRONMENTAL HEALTH DIVISION RECIRIVED 445 N SAN JOAQUIN, PHONE (209)468-3420 ,� t � P O BOX 2009, STOCKTON, CA 95201 SAN JOAQUIN COUNTY PERMIT EXPIRES 1 YEAR FROM_ DATE ISSUED- PUBLIC HEALTH SERVICtS . (Complete in Triplicate) NVIRONMENTALHEALTHDIVIMN Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. " Job Address 0 'r City Lot Size/Acreage Owner's Name Address Phone l j 4&4- Contractor ass License No. ti.7 �Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION 13SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Is AL FLO. PROP. LINE 'FOUNDATION AGRICULTURE WELL ER WELL PITS/SUMPS INTENDED USE TYPE OF..WELL PROBLEM AREA . CONSTRUCTION ECiFiCATIONS L1 Industrial ❑ Open Bottom "` ❑ Manteca Dia. of Well ation Dia. of Well Casing Cl Domestic/Pris'ate 0, Gravel Pack ❑ Tracy Type of C ng Specifications Il Public til Other n Delta Depth Gro Seal Type of Grout r I I Irrivation 1 =4 a: Approx. Depth 11 Eastern Su ace Se Installed by Repair Work Dome L3 Type of Pump H,P. Stats Work Done_ ' Well Destruction ❑ Welt Oiarrieler' ' Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: ' NEW INSTALLATION ILT REPAIR/ADDITION I I DESTRUCTION I I {No septic system permitted if public sewer is avaiWbla within 200 feet.l Installation will sgrv95 Residence Commercial titer Number of living units: Numberof-bedrooms Character`of$oil to a°dapth of 3 feet: on Water table:depth SEPTIC TANK1 ❑ jype/f>rlfg Capacity No. Compartmahts PKG. TREATMENT PL ❑ M . r Method V D' } r Distance to nearest: Well ndation &AlProperty Line .. LEACHING LINE 0 "No.-,& Length of lines Total ngth/size C FILTER BED ❑ Distance to nearest: Well unoation Property Line � a SEEPAGE PITS 11 Depth 5iie 0 0N r SUMPS CI Distance to near t: Well LillIAVFoundation A Propefiy 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 oldinances, state taws, 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 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 s 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 anus It for all r ed inspec ions. Complete drawing on reverse side. Signed Title: __ Date: FOR DEPARTMENT USE ONLY Application Accepted by `,4 & ' Date 7 1 Area Pit or Grout Inspection by Date, Final Inspection by Date 7 A Additional Comments: M Applicant-•- Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Servicesfn� 445 N San Joaquin, P O Box '2009, Stkn, CA 85201 ((jj��JJ { IFEE AMOUNT DUE AMOUNT.REMITTED CASH . RECEIVED BY DATE PERMIT NO. �1�l] �NF Q7 • EFH 3-24 H 1�Za 1REV.r i r a t Ij f/ e 0 o 1` ��0 77 r