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it 7 A$PLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH_ DIVISION 445 N SAN JOAQUIN, " PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 f w�� ',e�fc, 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. 549 {d 1862 and the"Rules and Regulations of San Joaquin County Public Health`Services.` r v^y� e Y � �3 y 17 /9 V Job Address ® r`� ' 4�N �s*� 0` City t'Vr .TT C" Lot Size/Acreage ! Gr j Owne('s Name i! ' Address C n s�01 E_—/L!`I 1 CJw h c�c s+pltonB � n `/ ..—� „ Con It actor Address rt'f ? 1). 16 License No, Q Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT r DESTRUCTION ❑ Out of Service We11 0 PUMP INSTALLATION ❑ SYSTEM REPAIR- OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP'LINE FOUNDATION '• AGRICULTURE WELL OTHER WELL PITS/SUMPS ¢ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS FI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1-1 Other I1 Delta Depth of Grout Seal Type of Grout I Irrigation” Approx, Dgp1 1 I Eastern Surf/ace Seal Installed by Repair Work Done ,K Type of Pump f] H.P. y Q State Work Done 12 � Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION k I No septic systempermitted if public sewer is i available within 200 feet.) ' Installation will serve: Residence_ Commercial_ Other v Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: t Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.0 Method of Disposal t Distance to nearest: Well Foundation Property Line r +� LEACHING LINE C1 No. & Length of lines ' Total lengthtsize I FILTER BED 11 Distance to nearest: Well ,"Foundation Property Line SEEPAGE PITS 11 Depth Size Number ` - SUMPS ll Distance to nearest: Well Foundation PropLine DISPOSAL PONDS ❑ .r erty 3 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: "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 persons subject to workman's compensa- tion laws of California." The applicant u all required inspec 'ons. Complete drawing on revs a ids. SignedX Title: Date. FOR EPAfiTMENT USE ONLY Application Accepted by � b.UA an&0&_La — Date Area Pit or Grout Inspection by Date Final Inspection by., Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE )NFO AMOUNT DUE AMO NT ti EMITTED CK RECEIVED BY O. TE PERMIT"N . EK 13.2 (REV.1/n51 EH �� Lts � u•2s 111 1