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APPLICATION IMO 335f r}� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Y 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 is made in compliance with San Joaquin County Ordinance No. 549 and 186 end the Rules and Regulations of San Joaquin County Public He lth Services.}�� Job Addres �� s Q +""IN's ! Cit Lot Size/Acreage Owner's NameZfie R'Y/etwf /H✓QS f M��ress � Phone449-- 17 «�. . � t'FRlk a♦ Z / License G / Phone Contract Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR Wo OTHER O 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.r CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom O Manteca - Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'I Public (a Other (-I Delta Depth of Grout Seal Type of Grout I I Irrigation / �.Approx. Dept Fti I I Eastern Sura a Seal Installed by Repair Work Done k Type of Pump J H.P. � State Work Done _ e OY AAq Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 111 . 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 f bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: a Foundation Property Line ^� LEACHING LINE Ll 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 arest: Well Foundation Property Line DISPOSAL PON S ❑ I hereby certify It at.1 have prepared this application and that the work will b done in accordance with San Joaquin county ordinances, state laws, and. rules and regulations of the San Joaquin County l,-' Home owner or li ensed 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 uch manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signat certifies t 'following: certify that in the pe ance of the work for which this permit is issued, I shall employ persons subject to workman's compensaa- tion law of California." The a plica for all i s. omplete drawing onersq/S>K,a. Signe !C Title: fe _ Date: FOR DEPARTMENT USE ONLY Application Accepted by Q- a.o� ��,oyW, Date �r� q Area ?J S"� Pit or Grout Inspection by Date Final Inspection by �' � !�' Date Additional Comm nts: t,10L, t V Applicant Return all copies to: SanJoaquin Cou ty Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P Box 2009, Stkn, CA 95201 -1N O AMOUNT DUE AM NT REMITTED K RECEIVED BY 0/0 E PERMIT'NO. �y/y . EH 13.41IREV.1irr5i EH 14-26 rte c� � !