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APPLICATION SAN �JOAQUIN COUNTY PUBLIC HE T11 ENVIRONMENTAL HEALTH DI I$ Cj 445 N SAN JOAQUIN, PHONE (29) 44� I 1 a P O BOX 2009, STOCKTON, Af"A�Qa PERMIT EXPIRES 1 YEAR FROM AfrEiA SUED (Complete in Triplic t Application is hereby made to San Joaquin County for a permit to construct and/or install the work here is 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 G� City& Lot Size/Acreage L Owner's Name�� r��«`z'�Z �' Address �� ^� Phone Contractor ( Address L �Z.k icense No. ��d 7.�/ Phone 3�C��I� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION 'D Out of Service Well ❑ 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 O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public FI Other f-1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. _-- State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t&-t—REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence J Commercial _ ther Number of living units: _4__ Number of bedrooms Character of soil to a depth of 3 feet: LWater table depth t.,ZZ SEPTIC TANK D�-Type/Mfg _�("-v�� L. r 4 '��'-- Capacity lL ' No. Compartments 2- PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well r Foundation Property Line LEACHING LINE El—No. & Length of lines �3� Total length/size � WeA_, -�� FILTER BED Distance to nearest: ll Foundation f Property Line e.�7J70 SEEPAGE PITS lit—Depth _Q 5 1 Size _� ` Number 1_ SUMPS LI Distance to nearest: Well `��' r Foundation •3 t 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 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 must call forall re wired in pections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY 7 Application Accepted by Date Z. Areay �� it or Grout Inspection by nZDate/d 2 Final Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. EH 1341(REV.s.n 51 EH 114e