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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION S 1 ,@ AWNED 445 N SAN JOAQUIN, PHONE (209)468-3420 QVVV �\Ill i'1JJIJ, 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health SS`eervices.Job Address Address -= /� i "i7 � City Lot Size/Acreage f © � Owner's Name C, dress Phone 4471710 Contractor selse No. Phone D TYPE OF WEL / NEW WELL F5 WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION C3 SYSTEM REPAIR El OTHER C3 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DfSPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public 1.1 Other fl Delta Depth of Grout Seat Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installad by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADOITION I I DESTRUCTION ( I INo septic system permitted if public sower is available within 200 feet.) Installation will some: Residence_ Commercial�ther� D �.p�-N,P q� Si, 3"ROr Number of living units: 4_ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg P�'" Capacity No. Compartments PKG. TREATMENT PLT. ❑ /► Method of Disposal Distance to nearest: Well 100 Foundation r Property Line aiioo LEACHING LINE Cl No. IS Length of linesTotal length/sizer FILTER BED ❑ Distance to nearest: Well .0 Foundation Property Line_� d p� SEEPAGE PITS 11 Depth Size Ny�mbar .yAM ,ems ^\ SUMPS LI Distance to nearest: Well Foundation--A 0 Property Line I" DISPOSAL PONDS ❑ 1 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 of the work for which this permit is issued, 1 shell 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: ")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 mu t call for all re, I ed m pa in s. Complete dra on reverse side. Signed die: Date: ` FOR '"Ti USE ONLY �1 c, plication Accepted by �Z, Date -yf� '�1//� Pit r Grout Inspection by� _as/IL.LI,/J.�d` at Final Inspection by 7_r �-!A (�' � Dale �� I / V Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ��/fAS', RECEIVED BY DATE/7�Z PERMIT'No. EM WMIREV.rrhmr •Q� lo �J �I -13 1J 3— ��