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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 mnde,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 Ho. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address � .e49 R lg:�S 7- -- City FC- Lot Size/Acreage SAG n e_ Owner's NameC-AAfA Address :SA_"e Phone - X,, ADS L7- Contractor Contractor F"yp ,t 06,Z7 Address 57"9W-A/ 9X za-/.i` License No. Phone 4`397 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT h DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER p Monitoring 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 C-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i'1 Public i-1 Other 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth l I Eastern Surface Seat Installed by Repair Work Done LJ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITiONAI DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence .11/Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: __— .A/Up- __ _ Water table depth �J SEPTIC TANK. ❑ Type/Mfg „�_ .Y 1 g7pi Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. & Length of lines _ -3 T-9,9 ` Total length/size FILTER BED n Distance to nearest: Well Foundation ifl Property Line __ID SEEPAGE PITS I7 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that t 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 I Home owner or licensed agent's Signature certifies the following: "I certify that in the petformance 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 alt required inspections. Complete drawing on reverse side. Signed X Title: Date. -S--97- 9-3 fiGR DEP ONLY Application Accepted by Date ` Arad a Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: Applicant - Return all copies .to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE A OUNT REMITTED RECEIVED BY DATE PERMITNO. INFO �J • EH 13'24(REV,r/xSl EH 14.7e