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n APPLICATION J SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (249)468-3420 � �� P O BOX 2009, STOCKTON, CA 95201 7 ,, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Q (Complete in Triplicate) Application Is hereby m&de.to San Joaquin County for a permit to construct and/or install the work herein described. This application is trade 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 City Lot Size/Acreage ^ Owner's Name Address Phone Contractor Address License N d'S-7• Phone `" �©3�x� �--�_i�-- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Ll # PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS PINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,..� ❑ Domestic/Private 0 Graver Pack ❑ Tracy Type of Casing- Specifications F [-I Public (a Other ❑ Delta Depth of Grout Seal Type of Grout I I trrit)ation _Approx. Depth I I Eastern Surface Seal Installed by fn Repair Work Done U Type of Pump N.P. _ State Work Done l Well Destruction ❑ Well Diameter Sealing Material & Depth a Depth Filler Material &,Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) # Installation will serve: Resi encs t! Commercial— Other - .Nurftbtr of-living-unitx._ —Number-of-bedrooms --- -—-` - --� - --- —- �" 1 Water table Character of soil to a depth of-3 feet;. depth t FSEPTIC TANK. IS—Type/Mfg - Capacity fl- No. Compartments , PKG. TREATMENT PLT, ❑ r / Method of Disposal i t Distance to nearest: Well_l1 Foundation c20 Property Line LEACHING LINE L"o. & Length of lines _ Q_. `Total length/size FILTER BED n Distance to nearest: Well /Foundation _Z Property Line C! r :7 ' SEEPAGE PITS 16t' Depth r Size r r Number SUMPS LI Distance to nearest: Well� � Foundation 1 cr7 r Property Line r DISPOSAL'PONDS ❑ I hereby certify,that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and, rules and regulation's 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of California." The applicant m It for all f896ired 'nspections. Complete drawing on rev rse side. Of �e Signed X ` — __ Title: __ tlt�.tlC 11 - Date: u FOR DEPARTMENT USE ONLY i7 { Application Accepted by -7_e_9 Date _ r Areay 2-- Pit or Grout Inspection by Date .Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services r � Environmental Health Permit/Services N 445 N San Joaquin, P 0 Sox 2009, Stkn, CA 95201 FEE INFO AMOUNT OUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT•NO. ,REV.t�K51104-1