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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 to hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This r application is made in compliance vith San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San YJ,lb Joaquin Countty Public Heaalth SServiices. _Address [� X111] Win. - City" Lot Size/Acreage Owner's Name t� �"L1 O _ Address ` � r b l u�`y -- Phone O , Contractor, 1 ` I �.wtldre55 License No. Phone O2 YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LI DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f,I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public 1-1 Other Fl Delta Depth of Grout Seal Type of Grout t 1 1 Irrigation —Approx. Depth I I Eastern Surface Sedi installed by Repair Work Done U Type of Pump H.P. —_ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth r� Depth K+.. Filler Material TYPE OF SEPTIC WORK: NEW INS7ALLATiON 1 ! I 1 S%rIs tic system permitted if public sewer is file within 200 feet.) Installation will serve: Residence_ Commercial 0 her {"ItIoUt Number of living units: Number of bedroomsT�� fro I tJ Character of soil to a depth of 3 feet: +., Ft' o p.o _Pf Ingog i eWater table depth SEPTIC TANK. ❑ Type/Mfg C �giyy� ' ;`- ` No. Compartments on PKG. TREATMENT PLT. L1 Method f 1C3[J Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 3 SEEPAGE PITS 11 Depth Size Number SUMPS , LI 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 A rules end regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I comity 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 foil ng: "I certify that in the mance of the work for which t-hie permit is issued, I shall employ parsons subject to workman's com nsa tion laws of lif is." The applic t c I r a it s ction mplete dr n oa re side. 7 7 Signed e: 4 Date: " OFOR EPARTME T USE ONLYJApplication Accepted by "`x _`' -- _ _ . Date 6,-+� 3 .Area 0-2-16 R `1 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ' Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IEEE AMOUNT DUE AMOUNTNF I .REMITTED CASH RECEIVED BY DATE PERMIT"NO. r . Es,,a.�,inly.„Kms r-� .v--� 3 D83 AJ (,-17-U, q3 - f EH 11•Ie 1 1