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I IM 4 APPLICATION j? SAN JOAQUIN COUNTY PUBLIC HEALTHiS RVICES 3 ENVIRONMENTAL HEALTH DIVISION I 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, ;CA 95201 PERMIT EXPIRES1 YEAR FROM :IDATEI ISSUED I. (Complete in Triplicate) u Application is hereby made,to San Joaquin County for a permit to constructland/or4natall the vork herein described. This application is made in eeanpliance with San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. City Lot Size/Acreage Job Address Z. li lhlhy�yy Address I Phone Owner's Name -, ? � , nr � Address' ej� � Phone Conhactar WELL REPLACEMENT Q DESTRUCTION Out of Service Well LITYPE OF WELL/PUMP: NEW WELL ❑ Monitoring Well PUMP INSTALLATI0 ❑ SYSTEM REPAIR C7 OTHER 11 it DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES J�DISPOSiAL FLD,1� PROP. LINE FOUNDATION AGRICULTURE WELL THERJIWELO� PITS/SUMP�i9_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP,ECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavat: W Dia. of Welt Casing II fa pomestic/Private ❑ Gravel Pack I-) Tracy Type of Casing_ f �M Specifications]7� 1') Public 1:1 Other Cl to Depth of Grout Seal,t ` Type of Gr.A!n� I I Irritation Approx. Depth Eastern Surface Sedi Installed by �p } Repair Work Done L] Type of Pump H.P. tej�Work Done _ Well Destruction 0 Well Diameter Sealing Material & Dept fr Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION 1 I;�INo septic system permitted if public sewer is '{ available within 200 feet.) ,i Installation will serve: Residence— Commercial_ Other I Number of living units: Number of bedrooms r Character of.&oil to a depth of 3 feet: [ er blleeTdepth SEPTIC TANK O Type/Mfg Capacity r I�_ nts PKG. TREATMENT PLT. ❑ II �NREGi{E i posal `p Distance to nearest: Well Foundation TY LEACHING LINE ❑ No. & Length of tines ' Tota50 IN COON ILM FILTER BED Cl Distance to nearest: Well Foundation 1 p�}B UX N o- L SEEPAGE PITS 11 Depth Sue I{ Number SUMPS 0 Distance to nearest: Well Foundation I. �'Propemy Line DISPOSAL PONDS ❑ !N 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 cenifies the following: "I certify that in the peffor'inance 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." C"ontractor's hiring or sub-contracting signature certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall erttpiha' rsons subject to workman's compensa- tion laws of California." �# The applicant call r r fired inspe ions. Complete drawing on reve�rssey side.. 4 �I �1 /��Iii�.Cs $ Signed Title: �ru� Date: F EPARTMENT USE ONLY ;�j �J Application Accepted by Date IJ ! L Area it Pit or Grout Inspection by Date Final Inspection by Dateskobt Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services !i 445 N San Joaquin, P 0 Box 2009; Stkn;d CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY,° DATE PERMIT'N0. INFO CASH c.F� . EH 13.24Im.lima) v ' IC�fS V EH 14-25