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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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ( � 70 City ZLot Size/Acreage Owner's Name dress Phone s v l O Contractor s ense No.A2, Phone 2zit ,TYPE OF WEL / NEW WELL WELL REPLACEMENT F DESTRUCTION Cl Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR O 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C_1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications I"1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by t Repair Work Done ❑ Type of Pump H.P. -__ State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION Ir REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is r' 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 O Type/Mfg Capacity. 40 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well �7�►�=� Foundation Property Line LEACHING LINE Ll No. b Length of lines Total length/size FILTER BED C1 Distance to nearest: Well 1 Foundation Property Line SEEPAGE PITS I Depth Size N mber 4f SUMPS LI Distance to nearest: Well ,.Q� Foundation.A-r Property Line DISPOSAL PONDS ❑ t// 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." Contractors 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 all r �ed pe. io s. Complete dra on reverse side. Signed X Date: ly,�� FOR ARTMENT USE ONLY � plication Accepted by ►"� _ Date `-7 -� Are JPi r Grout Inspection by at Final Inspection by T �97'T 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 CASH CK III RECEIVED BY DATE PERMIT NO/. EH 13-24(REV,rih Sl EH/,.2%