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APPLICATION ` SAN AAQUIN COUNTY PUBLIC HEALTH SERVICES r ENV I RONMENTAL HEALTH DIVISION f r -- 445 . .,. 445 N SAN JOAQUIN, PHONE (209)468-3407,_ ^It ? HEAj_Tf1 P O BOX 2009, STOCKTON, CA 95201 j E PERMIT E%PIRES 1 YEAR FROM DATE ISS VCI - AMlr, 43 (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 �1 !�► Z ' City W Lot Size/Acreage IV Z Owner's Name 'r r � j ''Y� w Address b•BIn W6 BOM CLa qqS 0 Phone Contractor V�� Address 1 ✓� ,O V s "1 7(icense No. Phon67-3 4M TYPE OF WELL/PUMP: NEW WELL x WELL REPLACEMENT FI DESTRUCTION L) out of Service Well ❑ PUMP INSTALLAT,I'O�J ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring/Well 3 DISTANCE TO NEAREST: SEPTIC TANK _]t�[/K — SEWER LINES DISPOSAL FLD. PROP. LINE�� FOUNDATION AGRICULTURE WELL OTHER WELL�� PITS/SUMPS , INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS it f n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavate n^^ 2 Dia. of Well rasing oZ f Domestic/Private ravel Pack >OTracy Type of Casing_ l.! Specifications56K Iwo �� 1'1 Public Cl Other f-1Delta Depth of Grout Seal �s Type of GroutSr//11 lcr� I I Irrigation —Approx. Depth I I Eastern Surface Sedl Installed by otr Per Repair Work Done U 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 1 I DESTRUCTION I I INo septic system itrt I pis Iic sewer is availabl n 200 feet.! Installation ill serve: Residence_ Commercial_ Other Number of livin its: Number of bedrooms Character of soil to a of 3 feet: Water table depth SEPTIC TANK ❑ Type Capacity No. Compartments PKG. TREATMENT PLT. ❑ f Method of Disposal Distance to nearest: Well I n Property Line LEACHING LINE ❑ No. & Length of lipes Total len size FILTER BED ❑ Distance to rest: Well Foundation Property SEEPAGE PITS 11 Dept Size Number SUMPS -Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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: "1 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 applica ;ttl,c I for I equ' d inspections. Complete drawing on reverse side. Signed XTitle: ""VA Date: IF FOR DEPARTMENT USE ONLY Application Accepted by � Date � I Area �v Pit or Grout Inspection by Date Final Inspection by _ Date --- Additional Comments: fe��s 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 FEE INFO AMMiOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. . EH 13-24(REV.1/NS) (�• �.�� 1 �� EH 14.26 --_ 111 111 VVV