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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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. 544 and 1862 and the Rules and Regulations of San Joaquin County public Health Services. Job Address 476 City 69�rk Lot Size/Acreage legil XOR Owner's Name �` Address ��,�� 1aC �f Pr - Phone Contractor ,-Address 7 �, I°t� License No. � �2 Phone 7 TYPE OF WELL/PUMPNEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ f PUMP INSTALLATION_ ❑ -_ _ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well (3DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE � FOUNDATION AGRICULTURE WELL OTHER WELL PtTS/SUMPS _ C> �aINTENDED USED TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Botl6m TO.Manteca Dia. of Well Excavation Dia. of Well Casing [.1 Domestic/Private, ❑ Gravel Pack 'rLJ Tracy Type of Casing_ Specifications— ( I Public C) Other F1 Delta Depth of Grout Seal Type of Grout.... I I irrigation -Approx. Depth i I Eastern Surface Sedi Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Weil Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ! REPAIR/ADDITION I 1 DESTRUCTION f I INo septic system permitted J.public sewer is . "available within 200 feet...I- � installation will serve: Residence Z Commercial Other - Number of living units: Number of bedrooms !Y y 1 Character of soil to a depth of 3 feet: Water table depth T SEPTIC TANK. Type/Mfg Capacity JIAZ ja4t.11No, Compartments PKG. TREATMENTPLT. ❑ Method of Disposal r Distance to nearest: Well Fou dation � 1 Property Line -LEACHING LINT: No. & Length of lines ; � Total length/size f .;Z "' FILTER BED ❑ Distance to nearest: Well Foundation1 Property Line ,�Ilrj1,rI//-, -, SEEPAGE PITS j Depth .Sire �_ ._ _ Number 62, _ f SUMPS LI Distance to nearest: Well 'Foundation. Property fine • ,: } 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• 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 cf 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, l shall employ persons subject to-Workman's compensa- tion laws of California." '" The applicant must all for all required inspections. Comp a drawing on.reverse Aide. Signed X Title: t�J Data: �� -5' 15 FO DEPARTMENT iJS6 ONLY Application Accepted by ^� Date 4 , Area Pit or Grout Inspection by Date ,j Final In pection by. Date Additional Comments: e v er K*v� a '�/f�/,� E Applicant - Return all copies to: San Joaquin County Public .Health ServicesC'"-r"'�''- Environmental Health Permit/Services 445 N San'Joaquin, P 0 Box 2009, Stkn, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REMITTED ASR RECEIVED BY OATS PERMI7'NO. 8cJ ' . Et7.2sIREV.,,nai EHK14•2a y 0o 0.1 00 r" frl q