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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I)A 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) Application is hereby tads 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. U Job Address rl ��s� /� L Aha ��_ City Lot Size/Acreage .2 L 6L t7� .-- �d �/� -d/�� .A� __ Owner's Name /�/ Phone'? .fif=d dP'ess � r ContractorT.R&,X-I1i_ �4 PVddress �"OD4 N C11,40,ly A¢yrs License No.-&/3� Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER ❑ Monitoring Well 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications I1 Public (-I Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by IN Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION)` DESTRUCTION K (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence# Commercial_ Other Number of living units: _-4 Number of bedrooms Character of soil to a depth of 3 feet: Gw S, Water table depth SEPTIC TANK Type/Mfg C_aac!`1J�g Capacity Z4aC; No. Compartments 02 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well J:;�2 Foundation C Property Line LEACHING LINE ` No. & Length of lines Z Q ` Total length/size FILTER BED ❑ Distance to nearest: Welles Foundation Property Lined• 3&-V _ SEEPAGE PITS bd Depth ZX2' —Size_,Z7 Number SUMPS LI Distance to nearest: Well Z00 Foundation - 5F Property Line DISPOSAL PONDS ❑ 1 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 sub-contracting signature cenifies 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 applican call for all"ouad inspecti Complete drawing on reverse side. Signed X Title: gza G Date: FOR DEPARTMENT USE ONLY Application Accepted by Date b qt?> Area ` Pit or Grout Inspection ' Date Final Inspection by Date Additional Comments: .14 26*6 Applicant - Return all copies to: San J quin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK ECEIVED BY ATE PEEjRMIT'N0. . EH 13.24(REV.I M5)5� ``�5� // K!It� �5 /a EH 14-M // �' C J