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I 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 PERMIT EXPIRES X 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 Job Address I City_,ej;?AWC7 Lot Size/Acreage t r ; • Owner's Name ■ �+>L Address Phone - a� Contractor _ ff1�U�`'"' Address P>0 �License NaC-4—SC Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ i, DESTRUCTION ❑ Out of service We11 ❑ PUMP INSTALLATION © SYSTEM REPAIR 0 OTHER ❑ Monitoring Well - DISTANCE TO NEAREST: SEPTIC TANK'S SEWER LINES - DfSPOSA-L FL'D.--PROP-LINE---�--- FOUNDATION ! AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F) Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Wall Casing r-I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i 1"I Public i-1 Other ❑ Delta Depth of Grout Seal Type of Grout ? i I Irrigation __.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION" DESTRUCTION I I INo septic system permitted it public sewer..is - r t f available within 200 feet.l - . Installation will serve: Residence-9 Commercial_ Other - Number of living units: Number of bedrooms Character of and to it depth of feet: ' 7✓ L' Water table depth SEPTIC TANK. 1 Type/Mfg - Capacity No. Compartments PKG. TREATMENT PLT.j❑ �L+ Method of�Disposal .� ,Distance to nearest:: ,Well 10 Foundation, ee! r"' Property Line LEACHING LINE D No. & Length of lines ' Total length/size FILTER BED ❑ Distance to nearest'. well J Foundation Property One r f # SEEPAGE PITS 11 Depth Sizef Number I` f SUMPS LI Distance to nearest': Weft Foundation Property Line DISPOSAL PONDS ❑ f I hereby certify that 1 have prepared thisapplicatiod and'4GI: the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County % ; # Homeowneror IiCansed agent's aignsture.certifies the follbwiK :-"I certify that in the.peliorman6e-of'the ark for which this permit is issued, I shall not - employ any.person in such manner as to become iubjee't to workman's compensation laws of California." Cont?actora 's hlring or subcontracting signature certifies the following:"I,certify that in the performance'of-tfie work for which this permit is issued,'I shall-employ persons subject to workman's compensa- tion laws of California." The applicant muni call for,all wire inspee ions. Complete drawing on reverse side. - - - ! Signed X_ Title: Date' -- - FqJR DEP �TeE ONLY.., f Application Accepted by Date Are A # Date z Final Ins action by' Date Pit or Grout Inspection by p Additional Comments: s ` Applicant - Return all copies to: ISan Joaquin County Public Health Services •! 1 "Environmental Health Permit/Services i t #445 N San Joaquin, P O Box 2009, Stkn, CA 95201 r [ FEE. - AMOUNT-DUE"" —AMOUNT-REM ITTED' - K — '"!"'RECEIVED-SY"-°�—DATE-----'"�PEAMIT"NO:'— INFO • EM IG IREV.11 K5 /sS' /