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tVPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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 and/or install the work herein described. This application In made in compilance with San Jcaqulri Coun y Ordinance No. 544 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. � �-" Job Address �'ty �.•.,, r1.. – :ot Size/Acreage .�•�',"` , Owners Name 'r . Address f Phone." Contractor f-e Address '! f- License No. _Phone TYPE OF WEL0PUMP: NEW WELL G WELL REPLACEMENT i i DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION G SYSTEM REPAIR rl OTHER.❑'"" Monitoring Well L DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PRP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom 71 Manteca Dia. of Well Excavation Oia. of Well Casing DomII Private C] Gravel Pack -7 Tracy Type of Casing_. Specifications Public1 "Other` i Delta [ Depth of Grout Seal _ Type of Grout Irngauon _Approx. Depth ;I, Eh3tern Surface Seul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material L Depth _*411 Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo Septic system permuted if public Sewer is available within 200 feet.) Installation will sarve: 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 PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: We" Foundation Property Line LEACHING LINE: ❑ No. & Length of linea Total lengtWitize FILTER BED 11 Distance to nearest: Weil Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Welt Foundation Property Line DISPOSAL PONDS O 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 shell not amptoy 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 persona subject to workman's compensa- tion laws of California." Theapplicafit Must call for all required inspections. Complete drawing oft reverse side. ii Signed soil.• r Title: Date. FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: Applicant - Return all copies to: 5an Joaquin County Public Health Services C Environmental Health Permit/Services 445 N Sae Joaquin, P O Box 2009, Stkn, CA 95201 NFOAMOUNT DUE AMOUNT REMITTED CASHCK it- RECEIVED BY OATS PERMIT No. • EH 13-24 IREV. EH 1476