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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOA UIN, PHONE (209)468-3420 �,aJ 0 B X 2009, STOCKTON, CA 95 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. _ t MCI,6 Jab Address � City � Lot Size/Acreage Jl? Address one - Owner's Name G Contractor_ m- _— Address License No. Phone i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION o out of service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR 9 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �CONSTRUC,,IO_N.SPECIFICA.T.IONS�� •-yam "" '- = =T ' JN TENDED.USE__ �YTE_OF�M1I1 Ll PROBLEM-AiiEA Dia. of Well Excavation Dia. of Well Casing f 1 industrial ❑ Open Bottom O Manteca C.1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications 1'I Public 1-1 Other 1`7 Delta Depth of Grout Seal Type of Grout IIrrigation r Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done 1 Sealing Material & Depth t3 Well Destruction ❑ Weil Diameter - Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION 1 1 REPAIRIADDITION I I DESTRUCTION I I iNo septi`lable c-s sL 'milled if public se er is ava7 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 Capacity PJ IW. ,6 PKG. TREATMENT PLT. ❑ h Distance to nearest: Well Foundation Proper LEACHING LINE ❑ No. & Length of lines Total length/KZ FILTER BED n Distance to nearest: Well Foundation P 11VVr F'U V154Q� SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D 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 I, rules and regulations of-the San..Josquin County.- u Home owner or licensed agent's si nature ce 'les tfie following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any per n in such mann o e subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the fo ng; "I ertify i t rmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of f rni The applics t st f all r uif ns clions. Complete drawing on reverse side. Z` Signed Title: �.&1*2M7 Date: Z FOR DEPARTMENT USE ONLY !� Date Area Application Accepted by r 1 t� Data Pit or Grout Inspection by Date Final Inspection by Additional Comments: Applicant - Return all copies to; San Joaquin County Public Health Sery Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO ,.., ) / C j Q EK 13-24 EH 1616 IFIEV.I�h 5! �� V L! !a� / (O l � .