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a APPLICATION SAN JOAQUIN COUNTY PUBLIC HEA ENVIRONMENTAL HEALTH DI 445 N SAN JOAQUIN, PHONE (21 P 0 BOX 2009, STOCKTON, I Complete in Triplica ,Han l �� )0-#4zv ahafivED Ll Application is hereby made.to San Joaquln 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 andi the ules and Regulations of San �C� Public Health Services. ��/�i�� AMOUNT REMITTED Lot Size/Acreage l �a ?3� I AL4 Owner's Name,�% Q Address OCl�C.� Phone (t v� j� /- 'Ar t/J/ /�j'%� �j' Gf 4ddres-q3 2� �4�f�//�LLft+^ptt �/� f �� 7-012-7 License Pio. Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well tl 073 co PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 `7 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 F1 Industrial , ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing N Domestic/ Private ❑ Gravel Pack 0 Tracy Type Casing_ Specifications VI Public C1 Other fl Delta Depth of Grout Seal Type of Grout Y y i t I Irrigation _ Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H, P. --- State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth `Depth Filler Material &_Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I t t DESTRUCTION I I lNo septic system permitled,it public sewer is lA available within 200 feet.) Installation-will``serve: Residence T Commercial _ Other „ Number of living units: Number of bedrooms " Character of soil to a depth of 3 feet: Water table depth-' SEPTIC TANK © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 42'et�qC .sj —(5?0 Method of Disposal Distance to nearest• Well F oundaUon Property Line LEACHING LINE Cl No. 8 Length of lines 1 Total length/size FILTER BED n Distance to nearest: oWell Foundation Property Line „ SEEPAGE PITS I I Depth Size. Number SUMPS LI Distance to nearest: Well Foundation Property Line \ i DISPOSAL PONDS ❑ T i 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 �I 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, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 r uired inspections. Complete drawing onreverse ��, 4a ree;verse side. Signed Signed }�' / Title: =Lel/1/7-2it— Date: L_ //LI) '_// 2 G 6 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspeccttiionnn by Date Final. Inspection by Additionalf1 1Ln Jr r r 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 • EH 13.24 (AEV.'1 i n sl FH 11.20 .,Daae "S / °/ 7/- FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE., PERMIT' NO. 3 . v 073 co Da80 `7 /a / 4:' 3