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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRON1dENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009 , STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compiete in Triplicate) Application Is hereby made to San Joaquin County for a permit to construct and/or install the work' herein described. ni5 application in made in cespliance with San Joaquin County Ordinance Nc. 549 and 1852 and the Rules and Regulations of San Joaquin county Public Health Services. Jou Address tv Lot 5izeiAcreage Owner's Name Address '' Phone (/ �Gnir3LlOr _ — Address ` License No. Phone i TYPE OF WELLi PUMP: NEW WELL C WELL REPLACEMENT tk',, DESTRUCTION ❑ Out of Service Well ,, I PUMP INSTALLATION C SYSTEM REPAIR C: 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 C Open Bottom �a Manteca Dia. of Well Excavation Dia. of WBII Casing r I Domesvci Private ❑ Gravel Pack ❑ Tiacy Type of Casing_'` __ Specifications I Public ..7 Other 4r Delta E`.K Depth of Grout Seal Type of Grout.' Irvipaugn Approx. Depth .J,4,,Eavarn Surface Seal Installed by — ps o _,. rH.P". ...`.. State Work Done — epair Work Dane L] Type f Ffufrtip WBII Destruction ❑ Well Diameter Sealing Material it Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION t h DESTRUCTION I I (No septic system permitted d public sewer is ivatiable 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 © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size FILTER BED © Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Site Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that f 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 taws of California." Contractor's hiring or subcontracting signature Certifies the following: "I certify that in the performance of the work tot which this permit Is issued, I shall employ persons subject to wofkman's compensa- tion laws of California." The applicant I<t.call for all required inspeq ions.. Complete drawing on revere side. Signed X ' Title: Date: •` FOR DEPARTMENT USE ONLY Ir r_ i. 7. , ;. Application Accepted by .' _'... � r DateArea r i r,. Pit or Grout Inspection by `, ;" Date Final lnspeotion byil � '' '•f �- _ Date l Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Healtb Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASHIf T RECEIVED By DATE PERMI 'NO. Elf 1321{REV.t,M Si EH IC20