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`APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 -YEAR FROM DATE ISSUED I ` �Q! ` (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 and 1862 and-the Rules and Regulations of San Joaquin County Public Health Services. , � r- Job Address � ,� �0. ` t✓ L f. KCity Lot Size/Acreage Owner's Name�`-P � 'z;,✓0-f .5 Address Phone ContractorG�'[_ r�_ y -�✓1 Address Icense Ne d Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ �. PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE E FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r . \ L1 industrial ❑ Open Bottonii ❑ Manteca 4 :Dias-of Well Excavation "' -Dia. of Well Casing e"r�l�: ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications C1 Other �'" 'n-'Deita " ' 'Depth"of-Gr6bt Srjdf Type of Grout ' Irrigation _Approx. 2e P I Eastern Surface Seal Installed by Repair Work Done Jc� Type of Pump � H.P. 3 d State Work Done Cj Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 fast.) Installation will serve: Residence Commercial_ Other - Number of living units: Number of bedrooms \ Character of soil to a depth of 3 feet: t ' Water table depth }� SEPTIC TANK ❑ Type/Mfg' Capacity {4' No. Compakrhents t kt PKG. T14EATMENT PLT, 0 Method of Disposal Distance to nearest: Well Foundation `Property Lina /-� f C} LEACHING LINE Ll No. & Length of lines Total length/size- FILTER ength/size FILTER BED n Distance to nearest. Well Foundation Property Line ti SEEPAGE PITS 11 Depth ) Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina ' 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 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall empioy persons subject to workman's compensa- tion laws of California." F The appli nt a for all required ins tions. Complete drawing on re rse side. _ a Signed Title: l C fa_ Date: ylrl5l, EPARTMENT USE ONLY _ 1-'e11 Application Accepted by -g�r. r _ / �.5� Date- _ +� 4 L'. Area Pit or Grout Inspection by Date Final Inspection by * Data a2 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ' Environmental Health Permit/Services r 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 13-2�[REV.%/"5) r , EN 11.28 4 'i r