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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 PERMIT EXPIRES I 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ��j�y�; Job Address / �'+'�'"y�r- /�' City Lot Size/Acreage /7 Owner's Name ddress Phone ContractorC ddress CRACRO �G'.d� License No.4 Phone 7 9 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION A<Dut of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "�` DISPOSAL FLO. � PROP. LINE (2& FOUNDATION -- 1-_-- AGRICULTURE WELL �'�THER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L'l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17 ,`Aomestic/Private" Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public Cl Other 8 I"1 Delta Depth of Grout Seal ` ! Type of Grout I I Irrigation 23approrr. Depth I I Eastern Surface Seal Installed by Repair Work Done C3 Type of Pump H.P. S` St to Work Done Well Destruction " Well Diameter b -- -- Sealing Material & Depth Depth l Z4 14-- Filler Material & Depth i. t TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I k DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet-I Installation will serve: Residence_ Commercial_ Other f Number of living units: Number of bedrooms j Character of soil to a depth of 3 feet: Water table depth # 5 1 SEPTIC TANK ❑ Type/Mi9 Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line T LEACHING LINE C1 No. & Length of lines Total length/size \j FILTER BED C1 Distance to nearest: Well Foundation Property Line k SEEPAGE PITS 11 Depth Size Number 5 SUMPS LI Distance to nearest: Well' Foundation Property Line 1 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, Stale laws, an 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,.l 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 cenifies 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." i ^- The applica mus I r Red i tibns. Complete drawing on reverse side, Signed Title: (" °' Date: FOR DEPARTMENT USE ONL Application Accepted by II yy r pate' Area Pit or Grout Inspection by W. Date ea nal Inspection by !Dala,.,8 y � Additional Comments: a ��r Applicant - Return al cops to: San Joaquin County Public-Health Services �irba l ��rAu 4.1-alnte� Environmental Health Permit/Services rerun¢_ 445'N San,.Joaquin, P D Box 2009,,Stkn, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. LU+� f 0c). EH 13.24(REV.iin51 �_� `EH'14.26 — s ,r fit