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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES :NVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 r._. 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 andior install, the work herein described, .his application is made in compliance with San Joaquin `ounty Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Coun y Public Health Sex-vices. A l _ ,�-_...,:.�;yrs......--.�."✓......_w��':a";.1...-`�:.:::::....�:r• ;�. �;.y Lot Sizey Acreage Jot, Address _,.„;•� Owner's Name Address -' Phone - i Contractor Address License No... Phone TYPE OF WELL/PUMP: NEW WELL __j WELL REPLACEMENT it DESTRUCTION (.fir Out of Service Well L PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER.-C_--.. Monitoring Well 'bt" Lc. .,,. . DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE%i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack Tracy Type of Casing_ Specifications Public "Other'_ � Delta F t Depth of Grout Seal Type of Grout- - ' Irsigatson �Approx. Depth 1j 'Eastern Surface Seal Installed by Repan Work Done L] Type of Pump H P. State Work Done Wali Destruction ❑ Well Diameter Sealing Material 4 Depth Depth Filler Material Z Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I I INo sepue system perrnsned if pi)bl,c sewer rs 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 0 Type/Mfg Capacity No. Compartments Pit G. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED 0 Distance to nearest. Well 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 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 compansa- tion laws of California." The applicant Rtt t...6all Inr elf requuad inspect; ns- Complete drawl, on reverse si r , A e IG Signed x .:, .. �. f _ Tit t ..,. �_ '-'7 Date: r i FOR DEPARTMENT USE ONLY Application Accepted by `:�`r` Date `, Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 3 445 N San Joaquin, P O Boz 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED BY DATE PERM17 NO. E 11.26 Ehli4-I6 EV,iinsi i r `JC'; -f7'� .- `� �//{� `. ,_� ,C. -�C1 h