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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 KL# 7-0_lo+-(-44 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �9�fC: v •: (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 compliancelvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 7ZXJf7 mit ,p fJ lCity Lot Size/Acreage Owner's Name N,&N1 S4 Address Phone 2019y i Contractor ! Address �jZ7 IZ License No. Phone `) TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well, 4b, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tit C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Z 17 Domestic/Private Cl Gravel Pack' ❑ Tracy Type of Casing_4e 6LA 43 ?V1✓ Specifications I'1 Public Cl Other ' L 1 Delta Depth of Grout Seal 3—5 _ _ Type of Grout I I Irrigation — Approx.'Depth I I Eastern Surface Seal Installed by Repair Work Done 17 Type of Pump N.P. _ State Work Done_ Well Destruction ❑ Well Diameter Sealing Material 8 Depth Depth Filler- Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRIADDITION I ! DESTRUCTION 1.1 INo septic system permitted if public sewer is available within 200 feat.i Installation will serve: Residence-1 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 f Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line k LEACHING LINE 0 No. & Length of lines Total length/size } FILTER BED n Distance to'nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to'nearest: Well Foundation Property Line Qr1 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 %�l rules and regulations of the San Joaquin Mnty 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 nor 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 mufst call,for all required inspections. Complete drawing on reverse side. Signed X �L---1 Title: S A ! Date: FOR DEPARTMENT USE ONLY �Q L� Application Accepted by Date l� +�-� Area ` Pit or Grout Inspection by - ate 3 Final Inspection by ' Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services jy Environmental Health Permit/Services V 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE � AMOUNT REMITTED t�C k',, -RE}CEEIIVED BY DATE G PERMIT'N�O. . EH 13-21 TREY. i x sr /1 C JS U EH SI.26 !✓J LJ