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APPLICATION �i SAN JAQUIN COUNTY PUBLIC HEALTB(N..&RVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 9520 . 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 is made in compliance with San Joe in:county Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ' City Lot Size/Acreage Owner's Name Address � ZOVW7A-72 Phone / j1 a Contract 4- Nddresso`943 A;' cense No.4"7k Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION t of Service Well ❑ PUMP INSTALLATION �; SYSTEM REPAIR 0 OTHER ❑ Monitors Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 1 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL--- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C7 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation,ll Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications Il Public Cl Other n Delta Depth of Grout Sealype of Grou / y I I Irrigation _Approx. Depth -el Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. to Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth v Depth Filler Material & Depth a( TYPE OF SEPTIC WORK. NEW INSTALLATION ' I REPAIR/ADDITION 13 DESTRUCTION I l fNo septic system permitted it public sawer,is 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 ❑ Type/Mfg Capacity-- No. Compartments . PKG. TREATMENT PET.❑ Method of Disposal Distance to nearest: Well II foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Founaation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Cl 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 Cm=ty, 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�compen'sation laws of California." Contractor's hiring or suti-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." The appticsW9694II far a required i tions. Complete drawing.,on reverse side. Signed Title: �L�+Y� rl � Date.- FOR ate:FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection byDate x Additional Comments: _ S � ---_- - Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE 35 d Z CK INFO /AMOUNT DUE AMOUNT REMITTED CASH') RECEIVED BY DATE PERMIT'NO. . EM 11.24IHEV.I/Nsl L p 0fj 1 i5 14� �zzlq oe k. s3 . EM 14.26 V