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I APPLICATION Y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCBTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. 0$7` 1aos�6 , JLrQ_� City Lot Size/Acreage F Job Address _ p a Address � _ Phone /J 1 - 51L Owner's Name t�-� v� G Contractor a!'`f� Address ZV �(�'e-D Li� �'' ' Phone ry 76T6 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out or tiervice Well Ll Monitoring Well PUMP INSTALLATION O SYSTEM REPAIR OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK �� SEWER LINES ,_, DISPOSAL FLDrG_ PROP. LINE FOUNDATION / AGRICULTURE WELL �OTHER WELL - PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1140-23 Cl Industrial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing w Cl Domestic/Private ❑ Gravel Pack El Tracy Type of Casing__'��Q Specifications . I'1 Public (-1 Other n Delta Depth of Grout Seal Type of Grout-,�- �MQ Irrigation —Approx. Depth I I Eastern Surface Seal Installed by 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 I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.1 \may Installation will serve: Residence— Commercial— Other \ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Ca ity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well oundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size (� FILTER BED ❑ Distance to nearest: W Foundation Property Line c^\v SEEPAGE PITS 11 Depth 4Size Number \\ SUMPS LI Distance to nares. Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this apolfication 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 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 m t II for ired' Tons. Complete drawing on reverse side. / /ql— Signed X Title: �L '•� Date: FOR DEPARTMENT USE ONLY Application Accepted by _(�.�L�+e.� _ �.MDate �l' Z' Area d Date A f Pit or Grout Inspection by Date Final Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY D E PERMIT N0. i�. EH13.211REV.l�ns) INFO �/ �1/Q y✓.� � iQ �' (/ / ` � � � / EH 11.26