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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 /� {' � City r,672 of Size/Acreage � Tfir'!-t -k �� /il•/fI�Z�T! HJT tf�C. Phone Owner's Name !Kl Address eC - 114 } Contractor Addressicense Na �_e21' Phone - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ENT DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK /00 ' SEWER LINES DISPOSAL FLD. 1401t PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL SOS PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin X Domestic/Private X1 Gravel Pack ❑ Tracy Type of Casing___ ,PICC' Specifications I'I Public I-] Other n Delta Depth of Grout Seal A01 /n�Type of Grout / A I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by r�LLCCrC-t J Repair Work Done Ll Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted it public sewer is 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size (� FILTER BED C) Distance to nearest: Well Foundation Property Line v SEEPAGE PITS It Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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." 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 o reverse side. Signed X Z Title: v Date: �� FOR DEPART ENT U ONLY Application Accepted by 17 Date Area y Pit or t Inspection by a,q Fina Inspection by Additional Comments: in JA41, Applicant - Return all copies to: San Joaquin County public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 IEEE AMOUNT ^DUE AMOUNT REEMITTED'� CAS CK/,( s RECEIVED BY DATE PE MIT NO. EH 13-24 1REV.r i X 5)+' , EH 14.26