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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 I (Complete in Triplicate) Application is hereliy. made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in cotapliance with San Joaquin County Ordinance No. 549 and 1862 and tete Rules and Regulations of San Joaquin County Public Health Services. /�ct—je.✓ 7t✓ ZC4V C; C1 vc- Job Address 67019 rype City +✓Q Lot Size/Acreage 30 ax_12� /1�1 Tom!- .. Owner's Name .I lob 4QUC ✓�a Address / r�LL,1c�l�tU'Lvr� e, Znl -- Phone 7 Conttaclorfi � Hddress�_ License NosZZ Phone TYPE OF WELL/PUMP: _ NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLAT16N I SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST;-SEPTIC TANK ' ` SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n'-Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ` omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout i I I Irrigation _.Approx. Depth I Eastern 5 rf ee Seat Installed by Repair Work Done U�`Type"-of-Pump H.P. __ -State Work D na Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material,B:Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i•I DESTRUCTION I l {No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial; �' Other. Number of living units: Number of bedrooms a ' Character of soil to a depth of 3 feet: Water table depth `SEPTIC TANK. ❑ Type/Mfg Capacity 1 ' No. Compartments PkG. TREATMENT PLT. CI R Method of Disposal R Distance to nearest: Well Foundation` Property Line ,LEACHING LINE D No. 8 Length of tines Total length/size 4 FILTER BED { n Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this applica ' n and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin q911M + Home owner or licensed agent's signature&nifies 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 must call for all required inspe, tions. Complete drawing on reverse side, Signed X Title: /I > Date:/Ly &",P, �P� N7` USE ONLY 1 Application Accepted by Date Area Z Pit or Grout Inspection by Date Final Inspection by e _ Data A6 � �7 Additional Comments: ! Applicant .-. Return all--copies to: -,San-Joaquln,County Public Health Services Environmental Health Perrriit/Services - 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE A OUNT DUE AMOUNT REMITTED CK A EIVED BY DATE PERMIT'NO, l INFO + EH 13.74 IREV,r i n 51 EH 1426 r