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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ✓� ` �] ENVIRONMENTAL HEALTH DIVISION; l l 445 N SAN JOAQUIN, PHONE -(209)468-3420 No OA f� P 0 BOX 2009, STOCKTON, CA 95201 PERP T ESP RES Z.__YEAR FROM DATE ISSUED (Complete in Triplicate) �,�� ,•. Application is hereby msde,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 ealth Services � �. vJobAddress _ �`-�•1!��.�., , � City Lot Size/Acreage { ,,-'Owner's Name 10��4b S ddress V-1contraelorAddress��Z � License No. Phone TYPE OF WELL/PUMP: #y NEW WELL-0 WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD, PROP. LINE. `,L,_ ' FOUNDATION~ = AGRICUI TURI'WELL OTHER`WEI.L �` ; PIT /SUM INTENDED USE TYPE OF WELL *' PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.) Domestic/Private ❑ Gravel Pack ❑ Tracy Tvpe of Casing_._ Specifications I'1 Public I'1 Other n Delta Depth of Grout Seal Type of Grout I i Irrigation .Aplxox, Depth I I Eastern Surface Soul Installed by Repair Work pone_ LJ _Type_ of Pump H.F, State Work Done _ ` ' "'' Well Destruction- Well Diameter _,.... Sealing Material 1 A�th " Depth Filler Material b De th TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION DESTRUCTION septic system permitted ' i lie sewer is 'v�,I.able within 200 fe Ins will serve: Residence _. Commercial Other _ Number of living Number of bedrooms M Character of soil to a depth o Water table depth SEPTIC TANK ❑ Type/Mfg Capacit No. Compartments PKG, TREATMENT PLT, Cl f - Method of Disposal Distance to nearest: Well oun Property Line LEACHING LINE ❑ No. & Length of li Total lengt FILTER BED In Distance earest: 'Well Foundation Property Line j SEEPAGE PITS Depth- Size F Number 1 SUMPS SLI .Distance to nearest: Well Foundation Property Lina ClS L PONDS .0 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 PPP Home owner or licensed agent's signature certifies the following; l B g g: "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," 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 n3yrot c for squir inspections mplete drawing on reverse side. Signed K Title: } Date: —� PAitTMENT USIr_ONLY Application Accepted by Date .Area. d Pit or Grout Inspect' y D o _ Final Inspection by 1 Date Additional +;vmments: _ Applicant -� Return all copies to., 5 Joaquin County Public Health Services i APC4—ra(,t vironrnental health permit/Services 445 N San Joaquin, P O Box 2008, Stkn, CA 85201FEE WFFO j�AMOUNT DUE AMOUNT REMITTED p K REcglvED By 91ATE PERMIT'NO. �^•6/C/ 8H 123(ACV. 111 13.4.24 .. - -i �� YYY `� —Li �t