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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 . P 0 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 2-2-7/3/3 "` Z ' ✓er City r- Lot Size/Acreage Owner's Name Address 7/3 Ef Phone �- Contractor /VO4� - Addressµ /-� _!'�� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR )d OTHER ❑ 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 L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C3 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Pubiic f 1 Other Cl Delta Depth of Grout Seal Type of Grout Ixlrrigatiort __.Approx. Depth E I Eastern Surface Seal installed by Repair Work Done 0 Type of Pump �� H.P. © State Work Done.71, G P l dra Well Destruction ❑ Well Diameter Sealing Materiel & Depth } Depth Filler Material S Depth TYPE:OF SEPTIC WORK NEW INSTALLATION I ! REPAIRFADDITION # l ^DESTRUCTION I 1 INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial._.- Other f Number of living units: Number of bedrooms � � eT Character of soil to a depth of 3 feet: } i SEPTIC TANK 0 Type/Mfg ____ Capacity PKG. TREATMENT PLT. ❑ x of�i Distance to nearest: Well Foundation Props me i AN J0P,Q LEACHING LINE ❑ No. & Length of lines Total le"Nu 1V4SlON FILTER BED ❑ Distance to nearest: Well Foundation EN peRy Line SEEPAGE PITS 11 Depth Size Number r_ 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 st all for' 11 requir i ctiona. Complete drawing on reverse side. Signed Title: d '4lk F Date: FOR EPARTMgNT US D Application Accepted by Date rea Pit or Grout Inspection by Data Final Inspection b pat ' Addjt�nal Comment ��ll ¢d/iPcc4 4 49pplicant - Return all copies to: San aquin County Public Health Services Environmental Health Per /Services 445 N San Joaquin, 0 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOU 7 REMITTED CK RECEI ED Y DA7 PERMFT'NO. INFO • EN13-241rrEV,r/nsY EH i4.2a