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APPLICATION I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 If 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 herein11' 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. f Job Address �� Cy E City S7X,tJ _ Lot Size/Acreage I%,OX1Go f Owner's Name . Address 1-97 _i/ G$A or_ S T.�4/ Phone I� 9 - ;i Contractor -A1002) Address 7 Al, 4.PEe BE�B ' As'E License fro._ 4��27G _Phone 44 - 9 a _ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out ofp Service Weil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ i DISTANCE TO NEAREST: SEPTIC..TANK SEWER LINES DISPOSAL-FLD. PROP. LIN0E FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial 0 Open Bottom ❑ Manteca Dia" of Well ExcavationII Dia. of Well Casing I') Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specificationsl__ I'i Public El Other n Delta Depth of Grout Seal Type of Grout . + I Irrigation Approx. Depth I I Eastern Surface Seal Installed by '! Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter" Sealing Material & Depth ' Depth Filler Material & Depth I� TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION DESTRUCTION INo septic system permitted if public sewer is serve: available within 200 leet.i ! �. Installation will Residence!Z Commercial—' Other I Number of living units: I Number of bedrooms Character of soil to a depth of 3 feet: LA VWater table depth SEPTIC TANK { Type/Mfg ISL_ Capacity___LO No. Compartments 7i. PKG.,TREATMENT PLT. C7 Method of Disposal 1` Distance to nearest: Well .7.-070- Foundation_ /o __ Property Line ;i LEACHING LINE 0 No. & Length of lines a Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line I=. SEEPAGE PITS ( I Depth Size Number SUMPS Ll Distance to In rest: Well Foundation Pro 'I perry Line �� r DISPOSAL PONDS ❑ 1 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 p Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which this permitl'lis 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, 1 shall employ persons subject to workman's compense 1 tion laws of California." Ip _ ii The applicant must call for all required inspections. Complete drawing on reverse side, q Signed Title; 0 Date: FOR DEPARTMENT USE ONLY Application Accepted byf! . Date Area Pit or Grout Inspection by11 Date Final Inspection by !�Dates? Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services I� Environmental Health Permit/Services i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IM FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY D E INFO �j PERMIT'NO. . EH 13,24 IREV.rin51 CJr// f �� I� i V414,26 /!