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t 4 a * 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 E%PIRES 1 YEAR FROM DATE ISSUED • � � �/ (Complete in Triplicate) Appllcatioa a ereby made A. S.-r1k4-icounty for a permit to construct and/or install the rrork'herein described. This application is made in coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.. /�f��J Job Address - C �,�/?f:!!?„ ��r�City Lot Size/Acreage Owner's Name Address 0(044 &0e, phoneF-67--3 !7 Contractor Address r License No.�__Phone «�✓r� /fo'+ TYPE OF WEL /PUMP: NEW WELL ❑ WELL RE ACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Mon tori well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �T/' DISPOSAL FLD7'JC PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION t( n Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing E) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public FI Other n Delta Depth of Grout Seal T pe of Giput \ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by n Repair Work Done U Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material Ir Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.} Installation will serve: Residence Commercial— Other Number of living units: Character of soil to a depth o Water table depth SEPTIC TANK. ❑ T Mfg ' � pcity No. Compartments PKG. TREATMENT PLT. ❑ rnlit may have expired Ull Method of Disposal DistancProperty Line LEACHING LINE 0 No. & r 1l��ti I�dr pts"1 I!"� f sion Total length/size FILTER BED 0 Distance to nearest. Well Foundation Property Line FSEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property 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 ordinances, state laws, and F. rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "t 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 C rnla." The applicant cam f all requir in t' n Cole dra ing on reverse side. / FSigned itfe:� Data: L/ t FOR EP TMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date .Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services U, y Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 F, INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DAT PERMIT NO. iF • EH 13-24(REV.t i n 6) /6 _�ir I EM 11.25 i C/ Pte!