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f APPLICATION 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 X 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. Job Address City,.00V4ff?%6 Lot Size/Acreage t © �' Owner's Name _,�� ,S�tZ�L/ __ Address ._ fes/ � Contractor ..—Address �� phone a �, `" _Address /f . � e d License Ro,h �iPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Did. of Well Casing (.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications (Ir I'1 Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout �J I I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIRIADDITION I I DESTRUCTION I i INo septic system permitted if public sewer is Installation will serve: Residence''//s Commercial— Other available within 200 feet.) Number of living units: -I-- Number of bedrooms, k. _ Character of soil to a depth of 3 feet: 1 , . , Water table depth SEPTIC TANK Type/Mfg Capacity -"- No. Compartments PKG. TREATMENT PLT. ❑ Method of isposal Distance to nearest: Well fes— Foundation ^ Property Line 'fir LEACHING LINE 1 .No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 7r.� Property Line �T� SEEPAGE PITS 11 Depth ,0-, Si", /40 XA:C �y�N�umber SUMPS Distance to nearest: Well Foundation --P-Q= Property Line ! 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 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 must call forjll requ'red i pections. Complete drawing on reverse side. Signed X Title: '� Date:,,�,:F `�r . D ARTM US.E ONLY Application Accepted by x Date Areaf Pit or Grout Inspection byDate Final Inspection by Dam'/C 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 AMOUNT DUE_.:_,_. ,AMOUNT REMITTED CK RECEIVED BY DATE PERMt7'NO. INFO CRSH EK t3.2M(REV,r i M 51 EH