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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 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 herein described. This application is made in compliance with San Joaquin County Ordinance No. 54 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Af6dA&gbZ JaE42Z=a7 Q_ _&P City S x1 Lot Size/Acreage �� '� Xjr67y Owner's Name Tim (Z/ZX 4-E Address Phone &4 pe4 Contractor iiC:fL&.XQ G r W0.1e4) Address _2 A!, AbEltiB Qd� License No. arY7L Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, _ PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca 'Dia. of Well Excavation Dia. of Well Casing Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications F) Public C7 Other I_1 Delta Depth of Grout Seal Type of Grout I i Irrigation _Approx. Depth I I Eastern Surface Sedi Installed by -� Repair Work Done v Type of Pump H.P. --- State Work Done_ Well Destruction ❑ Well Diameter T Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRIADOITION I1--DESTRUCTION i I (No septic system permitted if public sewer is n available within 200 feet.} �J1 Installation will serve: Residence L Commercial_ 6tlyer Number of living units: ___ — Number of bedrooms -'S -- Character of soil to a depth of 3 feet: S GiL r 1 Water table depth j SEPTIC TANK ❑ Type/Mfg Capacity 12-0o No. Compartments / PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well ZVO Foundation"_10i Property Line —100 X- LEACHING LINE ieNo. & Length of lines 3 _ 4 „! Total length/size i 7-0 FILTER BED ❑ Distance to nearest: Well 1QQ_- Foundation _�_ Property Line 40W SEEPAGE PITS I I Depth o'2 r `Size� " Number 3_ SUMPS LI Distance to neaieat: Well Foundation lProperty Line Q 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, an rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "1 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 persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed l 3 g x-{ ( ._, � Tide: Dalai FOR DEPARTMENT USE ONLY w Application Accepted by _ Date � , Area' Pit or Grout Inspection by Date _F Final Inspection by Dots ddnal Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P Box 2009, Stkn, CA 95201 FEE YN QjJ( AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE /PERMIT NO. EH 14.20 /