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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 P, R,?pa` ✓ PERMIT EXPIRES X YEAR FROM DATE ISSUID (Complete in Triplicate) E 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 Joaquin County Ordinan a No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address e� City _-�` Lot Size/Acreage Owner's Name Address So. y-- t Contractor Address o! License Note 42La—�/TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] eDESTRUCTIONService We11 ❑PUMP INSTALLATION ❑ SYSTEM REPAIR 1& OTHER nitoring Well ❑DISTANCE 70 NEAREST:s'SEPTIC TANK SEWER LINES DISPOSAL FLD. EFOUNDATION AGRICULTURE WELL OTHER WELL PSINTENDED USE TYPE,OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation DomesticlPrivate G7 Gravel Pack ❑ TracT DiaasingY ype of Casing_ Sp I i Public I:7 Other , (-1 Delta Depth of Grout Seal 1 i Irrigation A Type of Grout pprox, Depth I Eastern Sur Seul Installed by Repair Work Dona Type of pump H P _ State Work Done Well Destruction Wali Diarnater" Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION'l I REPAIR/ADDITION i I DESTRUCTION I I INo se J available within 200 feet.)ptic system permitted if public saw s► is } i�.. Installation will serve: Residence` Coriimarcial^ Other _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK. Water table depth ❑,' Type/Mfg PKG. TREATMENT PLT. Cl• Capacity No. Compartments Method of Disposal Distance to nearest: well Foundation Property Line LEACHING LINE ❑ •'Na. &-Length of lines Total length/size FILTER BED Il ,.Distance to nearest: Wall- Foundation ,.• Property Line e SEEPAGE PITS 11 Depth- Size'.- Number SUMPS LI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state rules and regulations of the San Joaquin county taws, and Home owner or licensed agent's signature certifies the following: 1 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 fotlowing: "I certify that in the partormance of the work for which this permit is issued, I$hall employ persons subject to workman's compensa- tion laws of California." The applican t call for all requieed inspections. omplete drawing on rev a side. Signed X Title: Date: R EPARTMENT U5E ONLY Application Accepted by Date "��flZ `� Area Pit or Grout Inspection by Data Final Inspection by `7 Date Additional Comments: Applicant -- Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, 0 ox 2009, Stku, CA 95201 FEE A OUNT DUE AMOUNT REMITTED CK INFO RECEIVED BY DATE PER AIT'NO. • EH 1]-24 IREV.r i m s) - EH 14.20 ' y/�