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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 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. Job Address t Cit ' Lot Size/Acreage Owner's Name Address A OJ0.g,�j Phone WContractor Address icense No"�L`LriO Phone TYPE OF WELLeUML. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ll-Out of Service Well ❑ PUMP INSTALLATION ElSYSTEM REPAIR Q OTHER C3Monitoring well ❑ 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' ` Ll Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing A-Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout ! I Irrigation Approx. Depth I I Eastern Surface Sedi Installed by Repair Work Done Type of Pump H.P. State Work,Donel &4L am-naag 7_3 Well Destruction E) Well Diameter Sealing Material & Depth s� Depth Filler Material 3 Depth, TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i 1No septic system permitted if public sewer is available within 206 feet.) Installation will serve: Residence T Commercial Other t w Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth tJ" SEPTIC TANK C) Type/Mfg Capacity No. Compartments [ n PKG. TREATMENT PLT.❑ a4y4wFBiwp1 V Distance to nearest: Well Foundation Prope LEACHING LINE Cl No. b Length of lines Total lengtoluvi U 5 1997 FILTER BED n Distance to nearest: Well Foundation SEEPAGE PITS 11 DepthSire Nunibe? I } U NI TA HEAL SUMPS LI Distance to nearest: Well Foundation- 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 for all r uired inspections. Complete drawing on r rse side. Signed XII :` Title: ._. Date: FOR LY r Application Accepted by DateArea Pit or Grout Inspection by Date Final Inspection by r Date ry ri- Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 19 'F 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNyT�RREM1TTED ASH RECEIVED BY DATE PERMIT'NO. EK 13-24 M Ev.l i n 51 r�� o f r A.EH 14.26 PR !!?Zl... :.t..