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APPLIbATI01 FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �jLobo 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 1a made in coapliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address .��D ' � -�iti � City /l�F Lot Size/Acreage hL Owner's Name r / 6 Address Phone Contractor lft i rPllf , 9(ddress �£/ f f� License No. Phone TYPE OF WELL/PUMP: NEW`WELL WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well Q DISTANCE TO NEAREST: SEPTIC TANK 12 SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL Doo OTHER WELL�L�tL ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation G Dia. of Well Casi Domestic/Private ❑Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'I Public Cl Other fl Delta Depth of Grout Seal �� Ty of Grout r Irrigatilxt Approx. Depth I I Eastern -Surface Seal Installod by f t" i/h O r - Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material 0 Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ) DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of Irving units: Number of bedrooms ' L Character of soli to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg f Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal l+' Distance to nearest: Well. Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll 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 cenifies 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 ie issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicvt.must call al squired inspgctions. Complete drawing on r as side. Signed ^` Date: fR DEPARTMENT USE ONLY i Application Accepted by � w.y �i--;� ._.n Date.F-,'3 Area /fir Pit Grout I pection by � i$'` Date s Final Inspection by n Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boz 2009, Stkn, CA 95201 IEEE AMOUNT DUE AMOUNT REMITED CASH ECEIVED BY DATE PERMIT'N0. EH 13-24(REV.I/A$) `� lgfj EH 1�2e —