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-APPLICATION CATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 PO 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 is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public [Health Services. r [��y Job Address ` �a T VCity_r 7 Lot Size/Acreage Owner's Nam � a Address _. �0. - _ Phone Contfactar o Address 50e9 �49116? License Noi;�220 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 177 DESTRUCTION ❑ Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 i 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 i=) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation y Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications i"I Public CI Other n Delta Depth of Grout Seal • Type of-Grout ' µ .t . I f Irrigation —..Approx. Depth i Eastein S� ce Seal Installed by dq Repair Work Done X Type of Pump H.P. State Work Done �= Well Destruction ❑ Wall Diameter Sealing Material & Depth I Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I ttNoseptic system permitted if public sewer is available within 200 feet.) '4 Installation will serve: Residence Commercial_.M._ Other - v Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth ti SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ' Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE'PITS 11 Depth Size Number SUMPS LI 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 4 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 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 persons subject to workman's compensa- tion laws of California." The applicano slcall far all required ' spec1107Complete drawing on I ve se ids. i Signed X Title: P Date, FO DEPARTMENT USE ONLY Application Accepted by :hal Date . `q _ Area O Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health P rmit/Services 445 N San Joaquin, Box 2009, Stkn, CA 95201FEE I INFO OUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. . EH13.24(W.1i85) __RJ� EH 742! `` [l