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A � 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 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby rade to San Joaquin County for a permit to construct and/or install the Work herein described. This application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health S?,Z es. t' �t Job Address �r��"`f _ �itY`"�z �A--- Lot Size/Acreage Owner's Name Pi Address Phone - Contractor S 001, ( Address Phon 2 rS TYPE Of WELL/PUMP: N WELWELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTIC-TANK .•SEWER-UNE5+ 'QiSPOSAL FLD. PROP. LINE'` FOUNDATION- AGRICULTURE WELL OTHER WELL SW PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava ion Dia. of Well Casing Xpomestic/Private XGravel Pack ❑ Tracy Type of Casing_ Specifications / I'1 Public f7 Other O Delta Depth of Grout Seal f®dv� i' r T p; of Grou .�,,� i I I Irri ation A&_C_,L t t' g• 3�,Appro epth I i Eastern Surface Seal Installed by O Repair Work Done L] Type of Pump H.P. State Work Done _ ! Well Destruction ❑ Weil Diameter Sealing Material & Depth Depth Filler Material & Depth - TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I l INo septic system permitted it public sewer is ^ available within 200 feet.) ` \ PAYMENT Installation will serve: Residence— Commercial_ _ Other AY T t Number of living units: Number of bedrooms RECEIVE® Character of soil to a depth of 3 feet: Water tablet depth SEPTIC TANK: ❑ Type/Mfg Capacity No. Compaftwnt v 9 19 9Z PKG. TREATMENT PLT.4❑ Metho(6#Wj I NITY Distance to nearest: Well Foundation Propeny UrQUBUC HEALTH SEF,ViCES ENVIRONMENTAL Hai•°.LTH DIVG01`1 LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED 0 Distance to nearest. Well Foundation Property Line i SEEPAGE PITS I I Depth Size Number SUMPS LI -Distance to nearest:' '®°Well `Foundation � Property Line kt DISPOSAL PONDS ❑ f I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and II 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. � r Signed X��/ L I V 16i�3C�C�C�VJ __ Title: ;"t Y e_jA Date: �y��f' j r FDR DEPARTMENT USE ONLY k, Application Accepted by 4, 'IA�r t�^+�„ _—_ Date 2 Area ? Pita Gro inspection by Date Final Inspection by Date l6 3 / i Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services a _ Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK EiNFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y GATE PERMIT N0. EH 13-74 fREV.ris5i CH 14•2a + t