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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN- JOAQUIN, PHONE (209)465-3420 P O BOX 2009, STOCKTON, CA 95201 ., OA i 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 vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San h Joaquin County Public Health Services. �} Job Address �� '/ G'' —./ City e4 of Size/Acreage Owner's Dame , Address f� Phone ' Contractor Address cense No. .i?ri'/S� Phone TYPE OF WEL /PUMP; VNEW WELL ❑ WELL REPLACE ENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ ppp DISTANCE TO NEAREST: SEPTIC TANK /00 ' SEWER LINES DISPOSAL FLO. /16 PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL__.SL'_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA. CONSTRUCTION SPECIFICATIONS r� f=1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casin X DomesticlPovate Rj Gravel Pack ❑ Tracy Type of Casing_ - pvd Specifications ` I"1 Public f-1 Other n Delta ,-s Depth of Grout Seal Type of Grout , I I Irrigation _ Approx. Depth .1 1 Eastern Surface Seal installed by Repair Work pone Ll Type of Pump H.P, State Work Done_ Well Destruction ❑ Well Diameter Sealing Material 3 Depth Depth Filler Material A Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.l Installation witl serve: Residence_ Commercial _ Other Y ��ss Number of living units: Number of bedrooms 6 Character`'cf soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size110 FILTER BED ❑ Distance to nearest: Wall Foundation Property Line SEEPAGE PITS I I Depth; Size Number SUMPS LI 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 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 I 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 California." The applicant mus call for all required i pections. Complete drawing oq reverse side. Signed X Title: Date: FOR DEPART ENT U ONLY 7 2— Application Accepted by Date r ZZ Areain / Pit or r t Inspection by at `Fina Inspection by ""Date �z Additional Comments: r t " L4" Applicant - Return all copies to:. San Joaquin County Public Health Services t!, �'� (5- Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 Yew FEE CASH DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. [J� IN V . EH 13-2iiREV.i,ASi+' l iC�V �. l EK 14-26 °