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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 ezt�� A �+�� r��aVA City `qpQ'4 Lot Size/Acreage + Owner's Name S`t'y �� t'n �� Address �vC- WCDj kt-S ISID 04M1+04 Phone Contractor F C�L Addresse-coac—A Dr- License No. Nl+- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER E °nttoring well 0 ref bDrPPnf DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A A n industrial Ca Open Bottom 0 Manteca Dia. of Well Excavation___ 6 '_ Dia, of Well Casing !'t C_] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ "A Specifications _ f'i Public Cl Other n Delta Depth of Grout Seal _-___- __ Type of Grout �,, x_- I i Irrigation _Approx. Depth I I Eastern Surface Seal Installed by 'FtsL Repair Work Done U Type of Pump H.P. State Work Done, Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 fest,) Installation will serve. Residence Commercial_ Other S Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 13 Type/Mfg; Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE t Cl No. & Length of lines Total length/size FILTER BED U Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS a 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, 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 taws of California." Contractor's hiring or subcontracting signature cartifies 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 fired i tions. Complete drawing on reverse side. Signed X � / f�4Title: 166, 1T• S _ Date: oil FOR DEPARTMENT USE ONLY Application Accepted by _ Date ? Pit or Grout Inspection by ��] Date Final Inspection by Date/•Zy Additional Comments: t 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 /DtJE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EM143.]e 24(REV. EH te.V —16 yj 9y` ?s? Jam/ rJ t?