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x.. 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 I YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made,to Sin 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 and 1862 and the Rules and Regulations of San I Joaquin County Public Health Services. Job Address City ` O a Lot Size/Acreage �JE'�i 11 X /:!�IZ1 Owner's Name Address G �✓ Phone Contractor/4// Cfr 1.r _Address 2LI00 J✓ Gn/&o Geo License Na..�Jf �t_7.Phone TYPE OF WELLIPUMP: NEW WELL-0 WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L3 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 C:} Domestic/Private 0 Gravel Pack L1 Tracy Type of Casing_ Specifications I'! Public +ta Other f-1 Delta Depth-of Grout Seal Type of Grout I i Irrigation App(ox. Depth I I Eastern Surface Seal Installed-by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth n Depth. Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: -Residence— Commercial_ Other &.L/ZrJ Q Number of living units: I_ Number of bedrooms QZ (� Character of soil to a depth of 3 feet: C Water table depth C SEPTIC TANK R Type/Mfg Caft c - Capacity /-?n0 No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well J00 Foundation Property Line 100 r LEACHING LINE J- No. & Length of lines 62 �d Total Length/size FILTER BED ❑ Distance to nearest: Well ,_,2-5a4V Foundation 4 Property Line 60 SEEPAGE PITS K Depth _ Irl Size Number SUMPS Ll Distance to nearest: Welles Foundation 30_ _ _ Property Line �Q DISPOSAL PONDS ❑ _ I hereby certify that t 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 f 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 k 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." r The applicant st call for a!i5equired inspections. Complete drawing on reverse side. c� Signed Title: Date: Uo'—JJ� M FOR DEPARTMENT USE ONLY I Application Accepted by Dat res Pit or Grout Inspection by Date Final Inspection by Dateu4_ Additional Comments: f 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 5 FEE I AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. �. INFO CASH s a O EH 43-24 1REV.1/ 51 A iL VVV EH 4 w{ ZO