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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) aFP t'r ,�.� 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. l l t 1�r`� L(�Qr� tCP� TM3�! City IBJ Lot Size/Acreage L 73 ` 270`-�S Job Address _ ,�- .- r Py�l Owner's Name Address ?�_ �" V _-_ Phone Contractor L Address 3 _. License No. a5-Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well 0 UMP INSTALLATION ❑ SYSTEM REPAIR OTHER Q Monitoring Well C7 DISTANCE-TO�JEXREST: SEPTIC TANK" -" ' - ' -' SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS R Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing E) Domestic/Private I_ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications `,I') Public I:1 Other n Delta Depth of Grout Seal Type of Grout T Irrigation .Approx. Depth l I Eastern Surface Seat installed by apair Work Done 0 Xype of Pump [. H.P. State Work Done fn�� Well Destruction ❑ N Volt Diameter _ Sealing Material & Depth pth ;Z4�0f Filler Material S Depth �41I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I i DESTRUCTION I i INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other - Number of living units: Number of bedrooms Qz Character of soil to a dep h of 3 feet: - - - Water table de tl1 'moiV ED MENTq� SEPTIC TANK. ❑ Type/Mfg Capacity—. No. Compart ICEB PKG. TREATMENT PLT. ❑ Method of Di MR 2 2 1993 Distance to nearest: Well Foundation Property Line � -SAIWJOXQUIN COUNTY � LEACHING LINE 0 No. & Length of'Iines Total length/size-ENVIRONMENTAL HEAt-TH ts,s.—cdYAl FILTER BED ❑ Distance to nearest. Well Foundation Property Line f _ 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 rules and regulations of the jSan 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 perso 'n such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cartifies the fotlo i ; "Ice 1fy that in tha performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion lawso a t la." The applic t u t call for 11 requ re Pnspecf Complete drawing on r arse side. Signed Title: ' pate: FOR DEPARTMENT SE ONLY Application Accepted by f� Date - Araa Pit or Grout Inspection by i_- -__ _________ Date— Final Inspection by Date s ! . Additional Comments: I i Applicant; - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services r 495 N San Joaquin, P O Box 2009, Stkn, GA 95201 FEE INFO MOU�yNTTy DYE AMOUNT REMITTED SAS CEIVED BY D E PERMIT NO. EH 14-25 i•�