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APPLICATION Q SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' °, t7tENVIRONMENTAL HEALTH DIVfSION 445 N SAN JOAQUIN, PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATEISSUED : (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 comopliance Vith San Joaquin County Ordinance No. 549 and 1862 and.the.Rules- end.'Regulations of San Joaquin County Public Health Services. Job Address _ City da Lot Size/Acreage r Owner's Name ._'.OL- , y�,• � n�/�llL/D�}Address Phone Contractor ress <700 IS No. Phone TYPE OF WELT(PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION 14 Out_of.Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER .0 ' Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP,'LINE FOUNDATION AGRICULTUREWE!I-Lri - OTHEFt. WELL. _ - _PITS/SUMAS_, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f7 Industrial D Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing r fa Domestic/Private ❑ Gravel Pack D Tracy Type of Casing_ 5l3ecificatons' V I.1 Public (71 Other C1 Delta Depth.of Grout Seal. Type of Grout 1 I 1 Irrigation Approx..Depth I I Eastern Surface Saw Installed by i (I., Repair Work none U Type of Pump H.P. State Work D no '"�1 Well DestructionWell Diameto!r Sealing Material 6 Depth i. Depth a�'� _ Filler Material i De th } R P TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADDITION f I DESTRUCTION I I fNo septic system permitted if public'sewer is available within 200 feat.) Installation will serve: Residence Commercial Other - 4. '- a." d ±S Number of living units: Number of bedrooms Character of Boll to a depth of 3 feet,I SEPTIC TANK. No. i^ ❑ Type/Mfg .r.._.:.��..CapacitY` No. Coln tt �O PKG. TREATMENT PLT. CI k M fl � Distance to nearest: Well Foundation Pe t i. LEACHING LINE 0 No, S Length of fines ��t ! %11�. Total len _ FILTER BED CI Distance to nearest: Well FounOstion ^L h, ', ; T;,'� I' t��IVISION SEEPAGE PITS 11 Depth Size Number ^,SUMPS Ll Distance to nearest: Well Foundation Property Line D15POS;4l PONDS",` ❑.. 'r"' "�"�'^^';�--"�-- �-- -- - -4-,-�--=' _ ,�,..��-r-- I hereby certify that I have prepared this application and that the work will be done ireaccordance 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 permit is issued, I shall employ persons subject to workman's compensa. tion laws of California," The appfic caE!1r, requir Inspections. Complete drawing on r se sideSigned X TillDate:410 R DE R LYApplication Accepted bDate Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ' I Applicant - Return all copies to: San Joaquin County Public Health Services t t Enviroomental Permit/Services ! � h 0 ox 2009,, Stkn, CA .95201 1 FEEAMOUNT DUE AMOUNT INFO EMtTTED CK N RECEIVED BY DATE PERMIT•NO. r a - a EH 13•24 IREV,i r n tO - EH i62t+