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' APPLICATION - SAI OAQUIN COUNTY PUBLIC HEALT ERVICES ENVIRONMENTAL HEALTH DIVISION . 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 gER�dIT E%PIRES YEAR FROMTE IS U a (Complete in Triplicate) Application is hereby made to Sea Joaquin county for a permit 'to construct and/or install the work herein described. This application is made is compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Addresa a j ' City Lot Lot Size/Acreage Phone Owner's Name �- Address ctor �-�` I ! 3 --J.,�, .�i� = License Na. ContraAddress 5"1 Gj' •—Phone TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out M Service Wel ❑ OTHER.Q Monitoring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES K DISPOSAL FLD.— PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELLPITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 industrial ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation Dia. of Wall Casing L/ c PIS Specifications (R Domestic/Private l9 Grave! Pack ❑ Tracy Type of Casing Type of Grout r�,.•^f•7 r,J;'r,l.��• . Il Public to Other C1 Delta Depth of Grout Seal , 7Rl� _`r' — - I I irrigation pprox. Depth I I Eastern Surface Seal Installed by 5A . ifa Repair Work Done U Type of Pump H.P. State Work Done Well Destruction D Well Diameter j-- :,A` Sealir+g Material i Depth cz -..v.. - Filler Material i Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR IADDITION i I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence Commercial_ Other F Number of Going units: Number of bedrooms Water table depth Character of soil to a depth of 3 feat ' SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments ° PKG. TREATMENT PLT.O Method of Disposal 'Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 8 Length of lines Total length/sire FILTER BED ❑ Distance to nearest: Wel; Foundation Property Line SEEPAGE PITS 11 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 canifies 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 workmen's compensation laws of California." Contractor's hiring or subcontracting signature �u certifies the following: "I certify that in the performance of the work for which this permit is issued, !shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Title: Signed Date- -- FOR DEPARTMENT USE ONLY Application Accepted by Date Area q Pit or Grout Inspection byaatte !Z�•10'.7z"inal Inspection by Date 12 Additional Comments: ►I ' f �"' IV 'y d Applicant - Return all copies to: San Joaquin County Public Health Servicesa IDDEnvironmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95 (U J 15f FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED,.BY DATE PERM17•NO. INFO CA1SH1 1 7p p p` . EH 13.241rIEV.°/r71 �I ��! (Z.— 31 9H 14.215 ��II d .. I