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APPLICATION z2� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 17 Job Address�lz �- / City 0_rt Lot Size/Acreage Owner's Name ' /.+ Address J/2 r7a-�44'i k"-s" Phon,: J r"7 6 �y Contractor Address T-4 __ _ License N� _ Phone G �7 TYPE Of WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION GY SYSTEM REPAIR 0 OTHER p Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f.'] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f.YDomestic/Private ❑ Gravel Pack 0 Tracy Type of Casing— Specifications C1 Public _ C) Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation �.Approx. 0 p 11 Eastern Surface Soul Installed by mp I . Repair Work Done IV Type of PuH.P. State Work Done Well Destruction D Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.l �- -- installation wilt_Serve: LResidenba Number of living units: Number of bedrooms : PAYMENT Character of soil to a depth of 3 feet: t WatR to SEPTIC TANK 0 Type/Mfg ' Capacity No. partmen s PKG. TREATMENT PLT. CI i M btl�bflii S-92 to nearest: Well Foundation Propeat%Uigj{?L4f11 LW qn iN1'Y PUBLIC Ht'--A; LEACHING LINE Cl No. & Length of lines Total Iengt�l �.iViE,I?AL i fL[AuTr3 FILTER BED ❑ Distance to nearest: Well Foundation • Property Line SEEPAGE PITS I I Depth Size Number SUMPS CI Distance to nearest: Weil Foundation Property Line 3j 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 signatura 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 applicant t ca11 far alt re wired inspections. Complete drawing on reverse side. �j Signed X At'tle: Date: [ IV FOR DEPARTMENT USE ONLY Application Accepted by Date._f/_. ! ` Area Pit or Grout Inspection by Data Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P ox 2009, Stkn, CA 95201 IN FEE AMOUNNO�T OVE AMNT REMITTED CK ECEIVED BY TE PERMi7'NO. . EH13-24 1AEV,1I R 51 EH 114.18 �(�