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APPLICATION V 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) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application mader Bance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulation f San J004 Co C c lth/Services. A`.. ry Job Address '�"�+� ^ `S( _ - City� Lot Size/Acreage Owner's Name ad 46 Address c )U`/,f Phone 2� Contractor a+ ` a�S`t- Address O License J Phone �T z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK l as SEWER LINES DISPOSAL FLO. ISO PROP. LINE 10 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 16 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well CasingF ,v;L� omestic/Private Gravel Pack ❑ Trac Type of Casing- /dy� S Y o Tracy g_ pecifications I'I Public / El Other n Delta Depth of Grout Seal 1-Or7� �101 Type of Grout I i Irrigation )SO-3 JT?.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump -74Z H.P. 3 ___ State Work Done_ Well Destruction O Well Diameter Sealing Material 6 Depth i Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal. Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/,size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permtt'is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mu call J#r all r u'ed inspections. Complete drawing on reverse side. Signed X //� Title: 40 1-4x Date: ( — 7 3 DEPARTMENT USE ONLY Application Accepted by �� Date Z Area Pit 0#'GroulAspection by Date VIW103 Final Inspection by Dat Additional Comments: Applicant - Return all ct/o P_ieto• an oQun ntY Public Health Services ,)�//�� a AlCG�k, K�s.a,��i eo-�4,r4finvironmental Health Permit/Servicesrc ms ¢ rx 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95,101 t� tfG+-,lidL✓�Q� IF FE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT'NO. Web K'S . EM 1 .24(REV.r i n sl ^� �� (� EH t,.n c 3 r ��`i 3 1