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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 I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby trade 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. ! t 7-0) �T® Job Address - r City Lot Size/Acreage i Owner's Name dress Phone ! # Contractor5" s ense No, Phone I TYPE OF WEL /P NEW WELL WELL REPLACEMENT F) DESTRUCTION ❑ Out of Service Well ❑ t 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack D Tracy Type of Casing— Specifications } VI Public l7 Other ❑ Delta Depth of Grout Seal Type of Grout ` f 1 I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by r. t Repair Work Done L] Type of Pump H.P. _ State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth /Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ?41` REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence_ Commercial Other Cpt p K,,Y 4 �;, } PV.—Number of_lv_ing_units;_ __Rumber af_bedrooms_ 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 j f Distance to nearest: Well ;Z 4 Foundation _ Property Line LEACHING LINE 0 No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Founoatien ? Property Line ) b SEEPAGE PITS 11 Depth Size N mbar 67 SUMPS 0 Distance to nearest: Well Q�� Foundation Property'Line z DISPOSAL PONDS ❑ V_ ` ` 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 r } 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 subcontracting signature f certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to wofkman's compensa- tion laws of California." The applicant roust call for all re ed in pe io s. Complete dra on reverse side. Signed ills: ��^ Date: FJFOR ARTMENT USE ONLY S plication Accepted by Date -7Z ! Area Z N ( 3 Pit r Grout Inspection by �ia at _ Final Inspection by '•. '_ � 9T Date . 2- Additional Comments: Applicant -- Return all copies to: San Joaquin County Public Health Services I Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. FEH 13-2e IREV. E H 14.26 li �