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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County fora permit to construct and/or install the work herein described. This application is made in compliance with Sap Joaquin County Ordinance No. Joaquin County Public 51+9 and 1$62 and the Rules and Regulations of San jHealth Services. Job Address City SC Lot Size/Acreage Owner's Name [l' ¢ ti_ _ Address �-� 692!� �SG/yi-• Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring,Well C7 DISTANCE TO NEAREST: SEPTIC TANK 3 ANV-SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL DO` OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS {-J Industrial 0 Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing [A Domestic/Private Cl Gravel Pack - D Tracy Type of Casing_ Specifications I') Public 0 Other r Delta Depth of Grout Seal Type of Grout I i hri ationApprox. _ ' W g .�, Depth I I Eastern Surface Seal Installed by Repair Work Done U 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 1 REPAIRJADDITION l I DESTRUCTION I I-(No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other 9 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 PLT, ❑ t, . Method of Disposal Distance to nearest: Well Foundation .Property Line LEACHING LINE ❑ No. & Length of lines _Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth_ —Size Number SUMPS L) 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 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject toZorken's compensa- tion laws of California," The spplica 11 II equir ins ns. Complete drawing on re rse side, / Signed X Tit a: 01n,' Date: FOR DEPARTMENT USE ONLY ` G Application Accepted by Date /� � � Area 1-f ^_ Pit or Grout Inspection by Date 1 Ll Final inspection by pate Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services i Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE 11 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED Ely DATE . V 1 PERMIT'NO.. EH 3-24 IREV.iiR 51 wo EH 4-25 �� f �/'300 /4