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in APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 I� P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to S"I Joaquin County for a permit to construct and/or install the work herein described. This application is made in complianceiwith San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address v "� � ' � City Lot Size/Acreage Flyf � � L�ddress.,..,'L/-3In Phon VVV Owner's Name i� Conhactor Address License No. Phone ' T E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: NK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE Of WELL PROBLEM ARE TRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of We tion Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications CI Public (-1 Other ✓, Cl Delta Depth of Groul-Seal' � Type of Grout t I Irrigation —Approx.'Depth l I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump. H.P. State Work Done , Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ 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 �� ppp Capacity No. Compartments t PKG. TREATMENT PLT. ❑ !!� IIpppMethod of Disposal Distance to f nares F%vAV' Fou rty Line + LEACHING LINE ❑ No. & Length of lines �Permit may ha - VVf i W gth/size I �l, ,,+,�f� i e� FILTER BED ❑ Distance to nearest: �{3Y}°ial u5t �btedoperty Line I� SEEPAGE PITS I I Depth Sue L '` SUMPS CI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O t I 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 \ " nifi s the following: 1 certify that in the Home owner or licensed agent's e+ nature ce e g y performance of the work for which this permit is issued, I shall not g g 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 peraons subject to workman's compensa- tion laws of California." The applicant m allfor 11 required inspections. Complete drawing on reverse /kAside. // + V IV f Signed Title: Date: 'r OR�EPTMENTUSE ONLY Application Accepted by ;+ Date Area Pit or Grout Inspection by i Data Finei Inspection by Date Additional Comments: l l t1 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services -445 N San Joaquin, P 0 Box 2009, Stko, CA 95201 FEE AMOUNT DUE 4� AMOUNT REMITTED CK ECEIVED BY D E PERMIT'NO. INFO « EH 13-24 IREV.+/MSl EH 11.20 . 5�) W.