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APPLICATION M G 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 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. (� (��t�cy Job Address I rl�� l a; ��r\ I`J7 City. J� 1 Lot Size/Acreage lop Owner's Name"' ' 1 �1-4,A, Address c7C"�Vl ell -e— Phone Contractor t" ' )yY 'r6ress icense No.. i �a,�Phone �/�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME T n DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION O SYSTEM REPAIR O 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 CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 17 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications I'1 Public 1:1 Other n Delta Depth of Grout Seal Type of Grout I 1 Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done O 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 X REPA WADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is Awk;� available within 200 feet.) K/ Installation will serve: Residence_ Commercial__ Other Number of living units: Number of , ooms f Character of soil to a de th of 3 feet: ,r Water table depth r SEPTIC TANK Type/Mfg 6 Capacity If 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 BEDl Distance to nearest: Well Foundation Property Line _\ 3 X 25 4 IST-erz PO I SEEPAGE PITS 11 Depth _Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, an 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 cartifies 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 rgust call for all gquired insp ions. Complete drawing on raver side. Siert Title: Date: (`\ r__�> FQ DEPARTMENT USE ONLY Application Accepted by r-C. ._ 12 .ry Date b r� Area S Pit or Grout Inspection by Date Final Inspection by�3 � Yl Date /Z g/ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CK i CASH RECEIVED BY DATE (PERMIT'N0. . EH 13.21(REV.r i n 51 i� V �, „ e f' L—'�[ EH 1440 1• �..{A3�. ( + )e+